Request for Services

If you are interested in pursuing services from Mercy Corps Northwest, please complete the following form. We'd like to get a better idea of you and your business needs. Prospective Loan Program participants are encouraged to complete the Loan Inquiry form instead.

Contact Information
Name * First Last
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone * - (###) - ### ####
Email
Annual Gross Income:
Number of People in Household:
Business Information
Business Name
Type of Business
Years in Operation (or designate Startup, Prestartup)
Do you have a business plan?

Yes No
Do you have 12 months of financial projections? Yes No
Service Request Information
What kind of assistance are you looking for from Mercy Corps Northwest? What are your business goals?
Which Mercy Corps Northwest programs are you most interested in? Check all that apply: Business Seminars Foundations Business Course Loan Program Matched Savings (IDA) Program Other
Is there anything else you would like us to know about your business or personal circumstances?
How did you hear about our organization? Website Referred from a friend/coworker Referred from another organization MCNW-sponosored event Other
If referred from another organization, please list:
Have you attended a Mercy Corps Northwest Orientation?

Yes No
If yes, date of Orientation:

/ MM / DD YYYY
Mercy Corps Northwest specifically serves low-income entrepreneurs in Oregon and Washington. It is the policy of Mercy Corps Northwest to provide equal opportunity to all applicants and to ensure that there be no discrimination against any persons on the grounds of race, color, national origin, political affiliation, sexual preference, age, or sex. All information provided will remain confidential and will be used for determining eligibility, appropriate services and for accumulating statistical data for evaluating our organizational performance.

Request for Services

Request for Services

Contact Information

Business Information

Service Request Information