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Name of Company / Organization:*


Doing Business As (DBA):


First Name of Main Point of Contact:*


Last Name of Main Point of Contact:*


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


Main Point of Contact's Email Address:*

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:*


Company/Organization Website:


Business Phone:*


Describe the nature of the service your business provides:*


Tell us about your Business / Client Base:*


Does your organization offer loan products?*
Yes No

What was your organization's gross balance sheet at the end of last year?*


Does your organization offer grant programs?*
Yes No

How many employees does your organization have?*


Locations/States Served:* (Use Shift 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

Does your organization offer Technical Assistance?*
Yes No

What languages does your organization serve?*


Does your organization serve rural small businesses? *
Yes No

Does your organization focus on sustainability, environmental, or green practices? *
Yes No

What products would your organization like to partner on? *
(Use Shift to select multiple products)
SBA Non-SBA CRE Grant Programs Green Products USDA All

Would your organization be interested in a private label portal with Lendistry? *
Yes No

Expected number of referrals monthly:*


Is there interest in receiving a referral fee?*
Yes No

Is there interest in receiving impact reporting?*
Yes No

Is your organization a non-profit? *
Yes No

Is your organization a CDFI, MDI, Both, or Neither? *
CDFI MDI Both Neither

Are we permitted to use your Organization's IP?*
Yes No

How did you hear about Lendistry?*

Name of the Lendistry Point of Contact:
(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)