Capital Request Form
We have solid relationships with investors and lenders around the world. Please provide the following information to the best of your ability. If you feel uncomfortable with a question, leave it blank, or if the question does not apply to you, type N/A. After submitting this form, the funding manager will review and reach out to you within 24-48 hours. Then confirm a time for an introduction capital call. We look forward to working with you to help achieve your funding goals. All information will be kept strictly confidential.
Name of Borrower
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Information
Business Name
*
Company Website
Business Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
When was the business established?
-
Month
-
Day
Year
Date
Is the business currently operational?
*
Yes
No
N/A
What is the business average monthly income?
Exact amount or range of capital you are seeking?
*
State the primary reason you are seeking capital - use of funds
*
Are you seeking to raise money by selling shares or equity interests?
Yes
No
If you are currently raising money, how are you doing so? (From friends and family, Reg. D Offering, Crowdfunding, Reg A+)
What business loans or lines of credit do you currently have open? How much is each one and when were they opened?
The current number of employees, if any:
Current Revenue, if any:
What is the current value of the business, if any?
Please list your current assets, if any, including properties, receivables, equipment, long-term contracts
*
What is the expected value of the business after two years, if any?
How did you hear about us?
Mutual Non-Disclosure Agreement
*
Check here to indicate that you have read and agree to the terms of the Mutual Non-Disclosure Agreement. Please read the agreement using the link below:
Mutual Non-Disclosure Agreement.
Next steps...
Thank you for taking the time to complete our online form. After you submit this information, you will be directed to our appointment calendar to schedule a brief capital call with a member of our team to discuss your project. We look forward to working with you.
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