Business Funding Intake Form
Capital Broker Mr. Rod Ferrell
Contact Information
Name
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Business Name
*
Business Qualification
Do you have a business bank account?
*
Yes
No
Do you have an active EIN?
Yes
No
Do you have a 680+ Credit Score?
Yes
No
Not Sure
What state do you live in?
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Describe your business in a few sentences.
How much capital do you need?
*
Please Select
Under $10,000
$10,000 – $25,000
$25,000 – $50,000
$50,000 – $100,000
$100,000+
Are you open to building business credit?
Yes
No
Maybe
How long have you been in business?
Less than 6 months
6–12 months
1–2 years
2–5 years
5+
How many employees does your business currently have?
Just Me
1–5
6–10
11–25
26–50
50+
As a business owner, do you currently have life insurance protection?
Yes
No
Interested In Learning More
Do you need merchant services?
Yes
No
Not Sure
Do you know any other business owners who may need capital as well?
*
Yes
No
Referral Name
Referral Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Referral Business Name
Funding Results are REAL!
Please verify that you are human
*
Submit
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