Name *

First

Last

Email *

Legal Name of Business *

Operating Name of Business

Website

Phone *

Head Office Address (street, city/state/province/postal/zip)

In your own words, what does your business do?

In your own words, what is your biggest financial challenge at this time?

Do you own any other business?

• Yes
• No

Ownership Structure (Name/Role in Business/ Ownership %)

Immediate Financial Need (How much $ and Date Needed)

Biggest 3 customers / Terms of Sale/ Average Month Sales Volume $ with each

Bank Account for Business (Bank Name?/How much do you owe them? /Account Manager's Name)

Financial Statements Current to:

How often are they prepared?

Are any taxes past due?

• Yes
• No

If yes, please fill out the details below:

What were gross revenues for the following years: 2019, 2020, 2021, Year to date

Here is a list of the information that a lender is likely to ask for and you should be able to provide. Being able to provide accurate and timely information is important to the process and will result in the best possible proposal in the shortest period of time. Please provide what you can from this list along with this completed form:

• Your most current set of interim financial statements
• Second ChoiceThe last two year set of financial statements
• Your most current A/R and A/P aging (if applicable)
• A copy of your invoice along with backup and contracts
• A list of your top customers (names and addresses)
• A copy of any cash flow projections you have prepared
• A copy of any information that would help me understand your business better

In your own words, How did your business start? A short history:

Where is your business today?

What does the future of your business look like? Goals and exit strategy:

Submit