Capital Acquisition Form

1

Leverage Banking Intake Form

First Name

Last Name

2

Email

example@example.com

3

Phone Number

Please enter a valid phone number.

4

Business Name

5

Business Location

CIty. State/Province, Country

7

Your net worth (Assets minus liabilities)

More than $ 320K

Less than $ 320K

I am not sure

Other

8

Your Business Annual Revenue

9

Declared Personal Income for 2022

10

Funding you require

Less than $200K

$200K - $400K

$400 - $1M

More than $1M

12

Describe your business, its value to the community, and how it generates revenue.

14

Which banks have you applied to in the last 12 months?

15

Date