Intake Form – Working Capital Company Name* Contact Name* Contact Email* Contact Phone Number*Ownership Structure Names and Percentages Business Start Date Month Day Year Business Name and Type Business Location Business Website Story/Background of Business Amount of Funding RequestedHow will the funds be utilized? Timeline for Funding How will the funding be applied to make the business more profitible? Financial Results to date2018 Gross Revenue 2018 Net Profit or Loss 2019 Gross Revenue 2019 Net Profit or Loss 2020 Gross Revenue 2020 Net Profit or Loss Balance Sheet ItemsAccounts Receivable Value Cash Real Estate Value Minus Loans and / Type of Real Estate Equipment Value Minus Loans Inventory Value ( Non Thc products) Current Business Debt Guarantor InformationCredit Score, Net Worth, Average Three Year Income Current Product Demand and Purchase Orders (if applicable) Do you have a IRA or 401K from an employer you are no longer with?YesNoIf yes amount in that? Do you have jewelry, machinery, vehicles, gun or art collection or any other items of value to provide as collateral for a loan?YesNoIf so type of asset and value? How did you learn about us? Any additional files you would like us to see please upload here:Max. file size: 50 MB.NameThis field is for validation purposes and should be left unchanged. Δ
