First Name:*

Last Name:*

Business Name:*

Doing Business As (DBA):

Entity Type:*
501(c)(3) 501(c)(6) C-Corp Cooperative Corporation Joint Venture LLC LLC For Profit LLC Non-Profit LLP LP Non-Profit Organization Other Partnership S-Corp Sole Proprietor Sole Proprietor (With Employees) Sole Proprietorship Subcharter S Corporation Trust For Profit Trust Non-Profit

Employer Identification Number (EIN):*
Please do not use dashes (-). Nine digits number only.

Address 1:*

Address 2:

City:*

State:*
Alabama (AL) Alaska (AK) Arizona (AZ) Arkansas (AR) California (CA) Colorado (CO) Connecticut (CT) Delaware (DE) District Of Columbia (DC) Florida (FL) Georgia (GA) Hawaii (HI) Idaho (ID) Illinois (IL) Indiana (IN) Iowa (IA) Kansas (KS) Kentucky (KY) Louisiana (LA) Maine (ME) Maryland (MD) Massachusetts (MA) Michigan (MI) Minnesota (MN) Mississippi (MS) Missouri (MO) Montana (MT) Nebraska (NE) Nevada (NV) New Hampshire (NH) New Jersey (NJ) New Mexico (NM) New York (NY) North Carolina (NC) North Dakota (ND) Ohio (OH) Oklahoma (OK) Oregon (OR) Pennsylvania (PA) Rhode Island (RI) South Carolina (SC) South Dakota (SD) Tennessee (TN) Texas (TX) Utah (UT) Vermont (VT) Virginia (VA) Washington (WA) West Virginia (WV) Wisconsin (WI) Wyoming (WY)

Zip Code:*

Email:*

Website:

Business Phone:*

Main Point of Contact's Mobile Phone:*
(Must be able to receive SMS messages for 2 factor authentication)

Referred By:*
(If you have already been discussing a partnership with a member of the
Lendistry team, please enter their email. If not applicable, please enter N/A)

Describe the nature of the service your business provides:*

Tell us about your Business / Client Base:*

Locations/States Served:* (Use CTRL to select multiple states)
Nationwide County/Region Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware 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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming

Approximately how many loans have you funded in the last 30 days?*
None Up to 5 5 - 15 16 - 25 25+ 50+ 100+

Have you funded an SBA loan in the last 30 days?*
Yes No

Which lenders are you working with?

How did you hear about Lendistry?*

Are you Licensed?*
Yes No In Process Not Sure

License required?*
Yes No Not Sure

Licensed State(s): (Use CTRL to select multiple states)
Alabama (AL) Alaska (AK) Arizona (AZ) Arkansas (AR) California (CA) Colorado (CO) Connecticut (CT) Delaware (DE) District Of Columbia (DC) Florida (FL) Georgia (GA) Guam (GU) Hawaii (HI) Idaho (ID) Illinois (IL) Indiana (IN) Iowa (IA) Kansas (KS) Kentucky (KY) Louisiana (LA) Maine (ME) Maryland (MD) Massachusetts (MA) Michigan (MI) Minnesota (MN) Mississippi (MS) Missouri (MO) Montana (MT) Nebraska (NE) Nevada (NV) New Hampshire (NH) New Jersey (NJ) New Mexico (NM) New York (NY) North Carolina (NC) North Dakota (ND) Ohio (OH) Oklahoma (OK) Oregon (OR) Pennsylvania (PA) Puerto Rico (PR) Rhode Island (RI) South Carolina (SC) South Dakota (SD) Tennessee (TN) Texas (TX) Utah (UT) Vermont (VT) Virginia (VI) US Virgin Islands (VI) Washington (WA) West Virginian (WV) Wisconsinn (WI) Wyomingn (WY)

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