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Name

Title

Organization

Street Address

City, State & ZIP Code

Work Phone Number

Home Phone Number

Fax Number

Email Address

Web Site

Type of Financing
Choose One Refinancing Acquisition Bridge Loan Business Loan Equipment Financing/Leasing Equity or Reit Factoring/Leasing Hard Money Mezzanine Real Estate SBA/Bank Loan Start Up/Seed Venture Capital

Credit Rating
Choose One Excellent Good Fair Poor

Latest 12 Months' Revenues in US Dollars
Choose One 0 Under 250,000 250,000 to 1,000,000 1,000,000 to 2,500,000 2,500,000 to 10,000,000 10,000,000 to 20,000,000 20,000,000 to 50,000,000 50,000,000 to 100,000,000 100,000,000+

Total Assets in US Dollars
Choose One 0 Under 250,000 250,000 to 500,000 500,000 to 1,000,000 1,000,000 to 2,500,000 2,500,000 to 5,000,000 5,000,000 to 10,000,000 10,000,000 to 15,000,000 15,000,000 to 30,000,000 30,000,000 to 50,000,000 50,000,000+

Cash on Hand in US Dollars

Credit Score

Do You Have Audited Financial Statements?
Choose One No, I Do Not Yes, I Do

If Yes, For How Many Years?
Choose One 1 Year 2-3 Years 4-5 Years 6-7 Years 8-9 Years 10+ Years

Business Type
Choose One New Existing

Total Project Cost in US Dollars

Requested Loan Amount

Plan for Repayment

Description of Collateral/Property/Business

Use of Proceeds

Please Use This Space For Any
Additional Information You Would Like Us to Consider

Do You Certify the Information You've Provided Above
Is True and Correct to the Best of Your Knowledge? Choose One No, I Do Not Certify the Information I've Provided Yes, I Do Certify the Information I've Provided