Fld Name / Instruction Item No. PART A Applicant – Items 1 – 3 are completed by all applicants. 1 Enter the legal name, and list all names the business is applicant’s exact full Exact Full Legal currently using. Name 2 complete mailing address, physical address if different from Enter applicant’s Address mailing address. If operating as an entity, list where incorporated or otherwise registered. 3 Enter the home or cell telephone number, as applicable, and e-mail applicant’s Contact address. Information PART B Individual Applicant Information – Items 1 9 are completed by the applicant. *Items 7-9 are voluntary. Item 10 is for FSA use only. – 1 Social Security Number (9-digit number). Enter applicant’s Social Security No. 2 Enter date of birth. applicant’s Birth Date 3 Enter the county where the operation headquarters is located. County of Operation 4 if applicant is a veteran. Check if not a veteran. Check “YES”, “NO”, Veteran Status 5 Check the appropriate block depending on whether the applicant is married, Marital Status separated or unmarried. 6 Check if applicant is a U.S. citizen. Check “Citizen”, “Non-citizen National”, Citizenship if applicant is a non-citizen national. Check if applicant is a “Qualified Alien” qualified alien. If non-citizen national or qualified alien, applicant must provide a copy of appropriate documentation of immigration status. 7 Check the appropriate box indicating ethnicity. applicant’s *Ethnicity 8 Check the appropriate box indicating the race. More than one box applicant’s *Race may be checked. 9 Check the appropriate box indicating the gender. applicant’s *Gender 10 Check the appropriate box indicating if the information collected was provided FSA Use Only or observed.
Fld Name / Item No. Instruction PART A – Applicant Items 1 – 3 are completed by all applicants. 1 Exact Full Legal Name Enter the applicant’s exact full legal name, and list all names the business is currently using. 2 Address Enter applicant’s complete mailing address, physical address if different from mailing address. If operating as an entity, list where incorporated or otherwise registered. 3 Contact Information Enter the applicant’s home or cell telephone number, as applicable, and e-mail address. PART B – Individual Applicant Information Items 1 – 9 are completed by the applicant. *Items 7-9 are voluntary. Item 10 is for FSA use only. 1 Social Security No. Enter applicant’s Social Security Number (9-digit number). 2 Birth Date Enter applicant’s date of birth. 3 County of Operation Enter the county where the operation headquarters is located. 4 Veteran Status Check “YES”, if applicant is a veteran. Check “NO”, if not a veteran. 5 Marital Status Check the appropriate block depending on whether the applicant is married, separated or unmarried. 6 Citizenship Check “Citizen”, if applicant is a U.S. citizen. Check “Non-citizen National”, if applicant is a non-citizen national. Check “Qualified Alien” if applicant is a qualified alien. If non-citizen national or qualified alien, applicant must provide a copy of appropriate documentation of immigration status. 7 *Ethnicity Check the appropriate box indicating applicant’s ethnicity. 8 *Race Check the appropriate box indicating the applicant’s race. More than one box may be checked. 9 *Gender Check the appropriate box indicating the applicant’s gender. 10 FSA Use Only Check the appropriate box indicating if the information collected was provided or observed.
FSA_2330_Instructions_Microloan_Application.docx