Business Questionnaire & Financing Application Form



Principal's Name:


Title:


Company Name:


Street Address:


City:    State:    Zip:


Telephone:    Cellular Phone:


Fax:    E-mail:


Web site:


Start-up    Existing Business   Years in Business

Sole Proprietorship    Partnership    Corporation


Amount of Financing Requested: $
Indicate minimum and maximum if applicable


Industry:
See list below or include own description if none are applicable


Purpose of Financing: 
Franchise Purchase    Equipment Financing    Start-up Financing
Working Capital     Receivables Financing      Factoring    Other:


Briefly Describe Purpose or Overview of Financing: 


Personal Guarantees Available: Yes     No


Credit History of Owner: Excellent Satisfactory Poor


Credit History of Company: Excellent Satisfactory Poor


If Stock:

Issue Price per share: $

Number of Shares:

Minimum Investment sought: $

Minimum Number of Shares:

General Information about Offer: 


Business Purchase Price: $  
If applicable 


Cash Invested by Buyer: $


Total Business Assets: $


Total Business Liabilities: $


Total Business Net Worth: $


Company's Annual Revenue: $


Company's Annual Net Profit: $



Board Members:

Chairman:

Managing Director:

Chief Executive Officer:

Company Secretary:

Non Executive Directors:


Key Corporate Advisors:

1. Role:

Name:

Address:

Phone:

2. Role:

Name:

Address:

Phone:

3. Role:

Name:

Address:

Phone:

4. Role:

Name:

Address:

Phone:

5. Role:

Name:

Address:

Phone:

 

Industry List: