All entries on the form are voluntary. Print or type all entries on the Form, OMB Control Number 2105-0554. The form is an electronically fillable form. We strongly suggest applicants utilize the electronically fillable form to complete the form entries. Illegible forms will delay processing time. Follow the instructions for each line to expedite processing and to avoid unnecessary requests for additional information.
Line 1. Full Legal Name of Business. Enter the full legal name of the business.
Line 2. Full Street Address of Primary Business Location.Enter the full mailing address of the business’s primary physical location.
Line 3. Website. If applicable, enter the business’s website address.
Line 4. Last Name. Enter the last name of the individual who will be the SBTRC’s primary contact with the business.
Line 5. First Name. Enter the first name of the individual who will be the SBTRC’s primary contact with the business.
Line 6. Title. Enter the title of the individual who will be the SBTRC’s primary contact with the business.
Line 7. Email Address. Enter the email address where the business may best be contacted.
Line 8. Area Code & Phone No. Enter the business or mobile phone number where the business may best be contacted.
Line 9. Fax. Enter the fax number where the business may best be contacted.
Line 10. UEI #. Enter the business’s Unique Entity Identifier # exactly as it appears in sam.gov If the business is not registered, register online at SAM.gov | Duns – Sam UEI .
Line 11. Registered in sam.gov. Yes or No.
Line 12. Type of Business Formation. Enter the legal formation of the business (Sole Proprietorship, Partnership, Corporation, LLC, ect.).
Line 13. Primary Trade or Services Provided. Enter a description of the goods or services provided by the business. Include applicable NAICS Code(s).
Line 14. Type of Contractor. Check the appropriate box to indicate whether the business is primarily a prime contractor or a subcontractor.
Line 15. Length of Time in Continuous Operation. Enter the length of time that the business has been actively providing goods and/or services.
Line 16. No of Employees (Last 3 Years). Enter the number of employees over the past 3 years. If the business has not been in operation for 3 years, enter “N/A’ in the years where the business was not in operation. Include the number of employees and specify whether they are W2s (full time employee) or 1099s(contractor) – as stated by the most recent payroll date.
Line 17. Revenue (Last 3 Years). Enter the business’s revenue over the past 3 years. If the business has not been in operation for 3 years, enter “N/A’ in the years where the business was not in operation.
Line 18. Certifications. Check all of the certifications held by the business. Please note that certification is not required to obtain assistance.
Line 19. Does the business currently hold a surety bond? The business should provide a response to this question if interested in bonding or financial assistance. Check the box to indicate whether the business currently holds a surety bond, and, if not, check the box to indicate whether the business or a principal in the business has held a surety bond in the past.
Line 20. Has the business or a principal in the business filed for bankruptcy in the past? The business should provide a response to this question if interested in bonding or financial assistance. Check the box to indicate whether the business or a principal in the business has filed for bankruptcy in the past. A “Yes” answer does not make a business ineligible for services provided by the SBTRC.
Line 21. Has a principal in the business had a prior felony conviction? The business should provide a response to this question if interested in bonding or financial assistance. Check the box to indicate whether a principal in the business has been convicted of a felony in the past. A “Yes” answer does not make a business ineligible for services provided by the SBTRC.
Line 22. Type of Assistance. Check the type of assistance that the business is seeking from the SBTRC. Provide a brief description of the specific assistance requested, such as:
1) technical assistance in a specific area, such as accounting, planning, contract review, marketing, bidding and estimating, project management, or financing;
2) financial assistance in the form of the DOT Short Term lending program, or other financial assistance; and
3) bonding assistance in the form of the DOT Bonding Education Program or other bonding assistance offered by DOT or other organizations.
Line 23. Region. Enter the name of the SBTRC Region. Reserved for entry by the SBTRC.
Line 24. Date. Enter the date of completion and submission of the Regional Field Office Intake Form to the SBTRC. Reserved for entry by the SBTRC.
Line 25. Client No. The client number assigned to the business. Reserved for entry by the SBTRC.
Line 26. Customer Base. Provide a brief narrative on who buys your products and services i.e. commercial, residential, local-state-federal government, general public, private organizations—general description.
Line 27. Date of Business Launch. This is the date of incorporation of the firm and is typically the filed date of the charter.
Line 28. Gross Profit Margin. Topline revenue minus expenses.
Line 29. Market Position. State if your business is considered a Leader in the industry, Top 1%, 10%, etc.
Line 30. Scale Aspiration. Briefly explain your interest in learning more about private equity and the prospect of expansion growth through partnering with a financial institution.
Line 31. Revenue and gross profit projected for next five years. Growth projection and rationale, general estimates will suffice.
