Name of Applicant Date of Submission RURAL BUSINESS INVESTMENT PROGRAM (RBIP) U.S. Small Business Administration, Investment Division RURAL BUSINESS INVESTMENT COMPANY (RBIC) APPLICATION PART I, MANAGEMENT ASSESSMENT QUESTIONNAIRE (MAQ) SBA Form 2241 Address Contact Person Telephone FAX Email Name of Person Submitting Application U. S. SMALL BUSINESS ADMINISTRATION INVESTMENT DIVISION 409 Third Street, SW Washington, DC 20416 Tel: (202) 205- 6510 SBA Form 2241 (5-04) OMB No 0570-0051 Exp. Date: 06/01/07