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COMPANY/ ENTITY  Short Form application – SUMMARY 

Please provide as much information as possible in a condensed form. You can add ssupplemental submissions or documentation to verify or prove the claims made on this form. This form is used for the beginning process of our loan and instrument lending programs, more as a quick summary guide.

Date of Submission:  
Registered Company Name:   

Registered Company

Address:

(Please provide full Address)

 
Incorporation InformationIncorporation Number:

Year Incorporated:
Country/

City of Incorporation:		   
Major Shareholders & %   
Name of Contact PersonPositionContact NumberEmail Address   
Name of 2nd Contact PersonPositionContact NumberEmail Address   
Bankers & AuditorsContactAddressCity, State, CountryPhone NumberLegal CounselContactAddressCity, State, CountryPhone Number  
 FUNDING DETAILS 

Seeking Funding

Amount of:(Currency USD/EUROS)   		 
Type of Funding desired:(Equity/Loan/Instrument)  
New or existing company to be funded?  
Funding Location(Where is company’s primary office?)  
Project Location   
Describe where else you have sought funding and the results of the search.  
Equity of Project Owner %  
Equity offered to Funder  %  
Type of Collateral available:(Amount)? (Liquid / non-Liquid)? (Own funds / sponsored)?

(Date of availability)

(Any foreseeable challenges)?		   
   

PROJECT DETAILS 

Use of Funds(Please provide

a brief description and include a complete breakdown)		  
Desired FundingSchedule & Description:   
Project /Business OverviwDescription  
Name your key competitors  
Why do you feel this project will be successful?  
Your current key resources and assets?
Is the company already
profitable?		  
Is there any real estate in this project? (Describe briefly)  
What are the available exit options for the investors?  
Are there any 3rd party Consulting Fees or Equity? Please provide full details.  
 OTHER
Your Current Investment in the Project  
In the past, have you any personal or corporate, judgments, liens, suits, criminal, convictions, foreclosures, bankruptcies, or other litigation active or pending that we need to be aware of prior to submitting your project to us?   
Why do you want to do this project? (These are personal reasons, not business reasons.)  
If we choose not to fund you, what is your next plan?  
What are your risks/loss if you cannot obtain funding?  
How long have you been looking for funding? To whom have you spoken?  

Until the project is success-

ful, what are you and your management team

prepared to do?

(i.e. compensation, etc.) 		  
Other disclosure