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Name of Company *

Are you currently in business? *

Yes

Business Start Date *

Business Street Address *

City *

State *

Zip Code *

County

Description of Business *

Business Phone *

Business E-Mail *

Business website

Name of Business Owner *

Type of Business *

NAICS code

Legal Entity *

% Woman Owned * Please enter as a decimal factor of 1. For example, for 50% female ownership, enter .5

% Male Owned * Please enter as a decimal factor of 1. For example, for 50% female ownership, enter .5

Is your business DBE (Disadvantaged Business Enterprise) Certified? *

Yes

Do you have a contract with MNDOT?

Yes

Is your business 8(a) certified? *

Yes

Is your business home-based? *

Yes

Do you conduct business online? *

Yes

Is your business WBE certified? *

Yes

Are you an exporter *

Yes

# of full time employees *

# of part time employees *

Total Employees

If you are in business, what is your average employee wage per hour? Enter only numbers and decimals, no symbols. Include yourself only if you are the sole employee.

For the most recent full business year, what were your gross revenues/sales? * Please only enter numbers without any symbols, commas or decimals. If none, enter '0'

For the most recent full business year, what was your owner annual compensation or draw? * Please only enter numbers without any symbols, commas or decimals. If none, enter '0'

For the most recent full business year, what were your +profits/-losses? * Please only enter numbers without any symbols, commas or decimals. If none, enter '0'

Does your business offer health insurance to employees?

Yes

If so, does it offer it to all employees or only those meeting certain criteria?

All

Some

Requested Loan Amount * Please only enter numbers without any symbols, commas or decimals.

Minimum $ amount needed * Please only enter numbers without any symbols, commas or decimals.

How soon are funds needed? *

Purpose of Funds *

# of new full time jobs that will be created in 1-2 years

# of new part time jobs that will be created in 1-2 years