Grant-Back Loan Intake Form

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First and Last Name*

Mailing Address*

Phone Number*

Email*

Social Security Number*

Business Name*

EIN or TIN, and Legal Structure (LLC/Sole Proprietorship, etc.)*

Year Established*

Number of Employees*

Have You Ever Filed for Personal or Corporate Bankruptcy? If yes, please explain briefly.*

Please Be Sure to Also Submit the Grant-Back Loan Application Form and Email Your Supporting Documents for a Complete Application!

13 E Main Street

P.O. Box 178

Cut Bank, Montana 59427

Proudly Serving All of Glacier County Including:

Cut Bank | Browning

East Glacier Park

Babb | St. Mary

Email

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