| Citizens Job Bank Pre-qualification Form |
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| Thank you for your interest in the Citizens Job Bank program. |
| Answer a few quick questions, click submit, and we'll contact you shortly. |
NOTE: The information you submit will remain confidential and will only be reviewed
by the NH Business Resource Center and Citizens Bank. |
| Fields marked with an * are required to process your form. Any errors found in your form will be displayed below the submit button. |
| 1. Contact Information |
| * Salutation: |
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| * First Name: |
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| * Last Name: |
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| * Title: |
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| * Company: |
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| * Address: |
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| * City: |
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| * State: |
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* Zip: |
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| * Phone |
(XXX-XXX-XXXX)
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| Fax |
(XXX-XXX-XXXX)
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| Website: |
(include http(s)://)
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| * Email: |
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| 2. Company Classification: |
| * Industry: |
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| * County |
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| * Company Description: |
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| 3. Operating Profile: |
| * Date of Establishment: |
(mm/dd/yyyy)
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| * Current Jobs (#): |
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| * Annual Revenue ($): |
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* Projected New
Jobs in NH: |
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* Loan Amount
Request ($): |
(Valid amounts between 240,000 and 10,000,000. No punctuation: $500,000.00 should be 500000)
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* Anticipated Use
of Loan Proceeds: |
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| For questions, please call (603) 271-2591. |
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