Massachusetts Capital Access Enrollment Form

Capital Access Program Enrollment Form

Name of Lender
Reserve Account #
EIN #
Loan Officer Information
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Phone
Borrower Information
Contact
First Last
Company Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
SIC Code
NAICS Code
Number of Current Employees
Estimated Number of Jobs Created
Estimated Number of Jobs Retained
Total of Other Indebtedness
Annual Sales
Years Incorporated/Formed
Special:
- Minority Owned
- Woman Owned
- Disabled
- Veteran
Loan Information
Lender Loan Number
Total Loan Amount
Covered Loan Amount
Borrower/Lender Payment
Maturity (Months)
Interest Rate (APR)
Date Loan Funds Available
MM slash DD slash YYYY
Date Reserved Payment Deposited
MM slash DD slash YYYY
Purpose
Loan Type
- Term
- Line
Fill out the following items ONLY IF REFINANCING A PROGRAM LOAN
New covered loan amount less prior amount enrolled must equal covered amount of this loan
Prior Amount of Loan Enrolled
Balance at Time of Refinancing
New Total Covered Loan Amount

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Headquarters

500 Edgewater Drive
Suite 555
Wakefield, MA 01880
Phone: 781-928-1100
Fax: 781-928-1101

Central Mass.

89 Shrewsbury Street
Suite 300
Worcester, MA 01604
Phone: 508-612-5661

Connecticut

20 Church Street
Suite 1740
Hartford, CT 06103
Phone: 860-218-2912

Maine

280 Fore Street
Suite 402
Portland, ME 04101
Phone: 207-773-3104

Rhode Island

30 Exchange Terrace
4th Floor
Providence, RI 02903
Phone: 401-450-0047

New Hampshire

3 Executive Park Drive
Bedford, NH 03110
Phone: 603-742-0078

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