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CAPITAL CONSORTIUM:
BUSINESS INFORMATION FORM
Is there more than one owner of your business?
Yes
No
If yes, list their name/s and percentage of ownership: Owner 1: ___________________________________ %_______
Owner 2: ___________________________________ %_______
Owner 3: ___________________________________ %_______
PROJECT INFORMATION AND CAPITAL NEEDS
How much funding do you seek? $_______________________________________
How much funding can you contribute? $_________________________________
What is the total estimated project cost? $________________________________
(if the project is a fit-out/renovation or to purchase equipment)
What do you plan to use the funds for? (check all that apply)
Renovate or fit-out the interior
Purchase Inventory
Renovate the exterior
Marketing
Purchase Equipment
Other _______________________________________
Working Capital
Describe the improvement you plan to make, equipment you plan to purchase, or how the money will be used:
FINANCIAL INFORMATION
Is your business a pre-revenue startup?
Yes
No
How many years has your business been open? ____ If incorporated, what is your date of incorporation? __________
Yearly Revenue
$0-$50,000
$50,001-$100,000
$100,001-$200,000
>$200,001
(average over last three years):
How much existing debt do you have? (Include personal and business debt)? $________________________________
How often do you do your bookkeeping?
Daily
Weekly
Monthly
Annually
Never
Do you have an accountant or bookkeeper?
Yes
No Do you use accounting software?
Yes
No
Created 5/2/2016
Page 2 of 3

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