We've detected that Javascript is not enabled. It is required for an optimal survey taking experience.
Please check your browser's settings and make sure Javascript is turned on. Learn how to enable Javascript.

Skip survey header

BUSINESS CAPITAL QUESTIONNAIRE

1. Date Questionnaire Completed This question requires a valid date format of MM/DD/YYYY.

calendar

2. If applicable, Deadline/Date Materials are Needed for Submission to Potential Funder. This question requires a valid date format of MM/DD/YYYY.

calendar

3. How did you hear about us? *This question is required.

4. Name of Company *This question is required.

5. Website Address *This question is required.

6. Primary Contact Person *This question is required.

7. Title *This question is required.

8. Email Address *This question is required.

9. Phone # *This question is required.

10. Mailing Address

11. Year company was Established *This question is required.

12. Fiscal Year of Business *This question is required.

13. Entity Type *This question is required.

Sole Proprietor
LLC
LLP
S-Corp
Other (please specify) Please enter an 'other' value for this selection.

14. Owners of Company *This question is required.

15. Total # of Current Employees *This question is required.

16. What kind of product/service do you provide? *This question is required.

17. Mission Statement *This question is required.

18. Products and Services & Suggested Prices *This question is required.

	Product/Service #1:
	Product/Service #2
	Product/Service #3:
	Product/Service #4:
	Other (please specify)

19. Target Markets: *This question is required.

	Target Market #1
	Target Market #2
	Target Market #3
	Target Market #4:
	Other Target Markets

20. Amount of Capital Needed/Amount of Funds Seeking *This question is required.

21. Summary of how Capital/Funds will be utilized (Purpose of Funds) *This question is required.

22. From what Funding Source are you requesting Investment Capital or a Loan?
*This question is required.

Private Investors
Venture Capital/Private Equity
Bank
SBA
Other (please specify) Please enter an 'other' value for this selection.

23. If applicable, What Percentage of Ownership Equity/Stock (Shares) are you offering in exchange for a capital investment?

24. Annual Revenue the last 3 years: *This question is required.

	Year 1
	Year 2
	Year 3

25. Projected Revenue for the next 5 years: *This question is required.

	Year 1
	Year 2
	Year 3
	Year 4
	Year 5

26. Are current Financial Statements Available? (Profit and Loss; Cash Flow; Balance Sheet) *This question is required.

27. Have Tax Returns been filed (last 3 years)? *This question is required.

28. Place an “X” next to any additional items that you have already fully prepared.

Pitch Deck
Pro Forma
3 to 5 Page Executive Summary/Investment Summary
Business Plan
A "Live" Website
Brochure/Other Written or Promotional Materials
Resumes/Bios of Management
Other Items (please specify) Please enter an 'other' value for this selection.

29. If any, how much Cash Collateral do you have to provide a lender if required to secure funding? *This question is required.

30. What other Assets can be provided as collateral for obtaining funding? (Equipment, Real Estate, Facilities, Accounts Receivable, Inventory) *This question is required.

31. What are your Debts/Liabilities (Loans, Property Leases, Other)? *This question is required.

32. If needed to qualify for funding, what is your Personal Credit Score? *This question is required.

33. If needed to qualify for funding, what is your Business Credit Score?

34. If applicable, has the Funder shared specific information they would like to be provided to assist them in making their decision?

35. Exit Strategy (How long do you plan to own the business? Do you plan to sell the business, merge with another company, or take the company public?) *This question is required.

36. Please provide a minimum of 3 days and times that are most convenient for you to schedule a time to review your “Business Plan/Investor Proposal” Questionnaire? *This question is required.

	Request #1
	Request #2
	Request #3