Please complete the following questions, then click 'Submit Questionnaire'.

General Contact Information

1. Your Name:
2. Company Name:
3. Daytime Phone:
4. Evening Phone:
5. Mobile Phone:
6. Fax:
7. Email:
8. Website:
9. Project Name:

Detailed Project Information

10. Name of the company or individual applying for funding and complete mailing address:

11. Names of the company owners and percent of ownership or key personnel and those being held accountable for repayment.

12. Provide a detailed description of the business, what the business does or is proposing to do, a view of the current financial condition of the company and who or what caused the company to be in it’s current position. (Please do not answer with lengthy cut and paste passages from a business plan).

13. Do you have a current business plan? (If so, please do not send it until requested)  Yes No

14. Indicate the amount of the funding you are requesting. (Please be aware that asking for too little can cause concern on our part. Ask for what you want; asking for too little is counterproductive).

15. Briefly describe how the funds will be utilized.

16. How long have you been actively seeking funding?

17. Where have you already sought funding, and what results have you had? (Having been turned down elsewhere will not necessarily jeopardize this request)

18. Please describe the type of funding you are requesting and why? (ie debt, equity)

19. Describe the types of collateral you will be using? If none, how do you propose to minimize the risk to our investors?

20. Are you using real estate as collateral?  Yes No

21. If you will use real estate as collateral is there a current appraisal that is less than 6 months old?  Yes No

22. How much of your own money do you currently have at risk in association with this project?

23. Can you provide documentation of personally invested funds?  Yes No

24. Briefly list your experience, and the experience of your management team.

25. What is your company’s annual revenue, current or projected revenue?

26. List any personal or corporate, judgements, liens, suits, criminal convictions, divorces, bankruptcies, or other litigation active or pending that we need to be aware of. Any of these issues do not necessarily preclude you from funding but prior disclosure is required.

27. Are you aware of, and do you agree to our firm or the investor’s firm, doing a credit and background check on the corporation and its principals?  Yes No

28. Do you have any interest whatsoever, controlling, financial, partner etc. in any companies that will be suppliers to the company for which you are requesting funds? If so, please name these companies and your interest in them.

29. Do you understand that at the inception of the funding request which will be initiated by engagement documentation issued to you, you are expected to cover direct legitimate due diligence expenses? (The due diligence process includes some or all of the following; civil, criminal, corporate and personal background checks on all principals, hiring of accounting firm to run parallel proformas, property and lien searches, possible site visit, etc.)  Yes No