FUNDING REQUEST
Company Name:
Company Address:
Your Name:
Email Address:
Telephone:
Fax:
Investment Amount Sought(US$):
Use For Funds Requested:
Financing Stage
Seed
Start-up
Early Expansion
Second or Later Stage Expansion
Management Buy Out/Buy In
Pre-IPO
Merger and Acquisition
Turnaround
Other
Latest Fiscal Year Sales Amount (Approx.)(US$):
Estimated Months To Profitability
Already Profitable
0-6
6-12
12-24
24-36
36+
Not Sure
What Is The Status Of Company's Business Plan
Not Started
Work In Progress
Mostly Finished
Ready
Needs Updating
What Is The Status Of Products Or Services
Conceptual
R & D
Prototype/Beta
Ready To Launch/Commercialize
Already In The Market
In The Process Of An Upgrade
Local Expansion
International Expansion
Year Found
Legal Structure
Corporation
Sole Proprietor
Limited Partnership
Limited Liability
Non Profit
Other
Number Of 'Full-time Equivalent' Employees
less than 10
10-50
51-100
101-500
more than 500
Enter Additional Information That You Might Consider Pertinent
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