The Carrot Project Inquiry Form

Complete only the sections which apply to your

business assistanceand/or loan request

  1. Contact information

Name:

Business Name:

Business Mailing Address: City:

State:Bottom of Form

Zip code:

Cell phone:

Office phone:

Primary email:

Enter any additional contact names, addresses, emails and phone numbers as needed.

  1. Please briefly describe your business, its products and services, and its history in 3-5 sentences.
  1. When did your business start or what is your anticipated start date(MM/YY)?
  1. What is your current or proposed organizational structure?

Sole proprietorship

Partnership

 Cooperative

LLC

 S-Corp

 C-Corp

 Other:

  1. How did you hear about us, or who referred you?
  1. Please enter the following historical and projected information for as many of the following years that you have been in business:

2013 / 2014 / 2015 / 2016
Gross sales or anticipated gross sales
Total expenses or anticipated total expenses
Owner’s Draw or anticipated owner’s draw
Number of employees (full-time equivalent) or anticipated
  1. Have you prepared a business plan and/or feasibility studies?

If yes, how or with whom were they prepared? (If yes, please email plans to .)

  1. Are you currently receiving any business or technical assistance? Please describe the type of assistance you are receiving.
  1. Please describe your target market, distribution channels and your five largest customers or potential customers.
  1. If you operate a farm business, please enter your acreage:

Total acres:

Productive acres:

Owned:

Leased:

  1. If you operate a non-farm business, please describe your base of operations (total square feet, leased or owned, etc.).
  1. What was your household income for the previoustax year? Please answer for each business owner living in separate households.
  1. Services requested: (check all that apply)

 Loan

 Business assistance

  1. Please explain your reasons for requesting this loan and/or business assistance. What are the intended outcomes? What changes, efficiencies, improvements in sustainability, or other benefits will result?
  1. If you are likely to need future rounds of financing beyond this application to meet your business objectives, please describe those financing needs:

Business Assistance

(Complete this section to request business assistance)

  1. What type(s) of business assistance are you requesting? *

business planning

loan preparation and packaging

cash flow budgeting

accounting/Quickbooks

growth/expansion

 financial planning

 enterprise planning

developing financial projections

 feasibility study

 specialized consulting

introductions with investors

 assistance with pitch preparation

*If the service you are looking for is not listed, please email ith your projected needs to determine how we can assist you.

  1. If you know, what date do you want to begin the assistance:
  1. If you know, by what date do you want to complete the assistance:

Loan Services

(Complete this section to determine eligibility for a loan)

  1. Amount of loan requested:
  1. What is the purpose of the loan?
  1. What is the total project cost?
  1. By what date do you need the funds?
  1. List sources of additional funds for this project:

 Personal/Business Capital: $______

Bank Loan $______

 Other Loan $______

  1. For how many years will you need the loan?
  1. Are you using any assets as collateral for another loan? If yes, please list theasset, loan purpose, loan amount, and lender:
  1. What assets are you intending to use as collateral for this loan?

List asset and value. (Such as: equipment, livestock, vehicle, land)

  1. Have you approached any other lenders about this loan request?
  1. Has another lender turned down your application? Which lender(s), and what were their reasons for denying the loan?
  1. Have you ever declared bankruptcy? Have you ever had loan or credit card accounts that were seriously delinquent, charged off or sent to a collection agency? If yes, please explain.
  1. Agricultural System Impact: What, if any, impact will your project have on the continued viability and growth of Pioneer Valley farms? (100 words or less)* (Examples: agricultural product/inputs are produced locally; value-adding activities take place locally; provides year-round value-added effort, benefits multiple farms/farm-related businesses, provides key piece of ag-related infrastructure, post-harvest activity such as handling, packing, processing, storage or distribution.)
  1. Community Impact: What impact, if any, will your project have on the economic, social, and/or nutritional health of the Pioneer Valley? (100 words or less)* (Examples: proven long-term commitment to PV communities; ownership structure encourages long-term local control; ownership focuses on providing social benefit; more local food to local community; increases food access for underserved communities; increases healthy/nutritional food access for local community; creates new jobs at a reasonable rate of return; creates new high quality jobs that include benefits, job training and/or living wages.)
  1. Local Environmental Impact: What impact, if any, will your project have on the environment? (100 words or less)* (Examples: improves ecological footprint by, for example, displacing food miles; improves farm-sector environmental practices; improves farm-sector energy use; re-uses pre-existing facilities; creates energy-efficient production processes for business.)
  1. Demographics Information (Optional):
  • I identify my race as: ______
  • I identify my gender as: ______

 I am a veteran

 I have emigrated to the United States

  1. Service Coordination Permission

Our organization coordinates with a broad network of service providers and lenders to serve our clients better.

 I agree that my business may be confidentially discussed with other lenders or service providers, only as it pertains to providing the services I requested above.

  1. Business Tracking Permission

Our organization is required to report on the outcomes of our work. We may request followup information in subsequent years in order to substantiate the outcomes of this work (such as change in business income or number of employees added as a result of this project). If you do not check this item you may not be eligible for certain services.

 I agree to be contacted for relevant business information to follow up on the outcomes of this project.

  1. Publicity Permission

By agreeing to participate in our outreach efforts, you ensure that other producers and processors can continue to benefit from our services. By sharing your story with others, you enable us to provide more of the lending and business assistance services that you are participating in.

I agree to be listed as a client for publicity purposes

Non-confidential information about me and the assistance I received may be used for publicity purposes

Photographs of me and my business and products may be used for publicity purposes

Signature ______Date ______

Signature ______Date ______

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617.674.2371