PRINCIPAL'S NAME:

Title:

Company name:

Street Address:

City:

Province / State:

Postal / Zip Code:

Telephone Number:

Country:

Cellular Phone:

Fax:

Email:

Start-up

Existing Business

Years in usiness:

Sole Proprietorship

Partnership

Corporation

Industry:

Amount of Financing Requested:

Purpose of Financing:

Franchise Purpose

Equipment Financing

Start-up Financing

Working Capital

Receivables Financing

Factoring

Other (Please Specify):

Briefly Describe the purpose of Financing

Personal Guarantees Available:

Yes

No

Credit History of Owner:

Excellent

Satisfactory

Poor

Credit History of Company:

Excellent

Satisfactory

Poor

If a Business Purchase:

Purchase Price  $