MEDC Loan Information Form

Borrower Business Name *

Trade Name or Doing Business As (d.b.a) *

Street Address *

Address Line 2 *

City *

State *

Zip Code *

Contact Name *

Title *

Phone Number *

Email Address *

Best mode of contact: *

Email

Phone call

Best time to contact: *

Do you have an established banking relationship? *

Yes

No

If so, which Bank are you working with? *

Estimated Financing Total Project Cost: *

Description: Provide a brief description of the use of loan proceeds and the projected project. *