Business Information

 Name of Business:

 Street Address of Business:

 City:

 County:

 State:

 Zip:

 Legal Structure:

 Nature of Business:

 Proposed Project

 Proposed Project Involves:

 Management Team:

 List Investment Partners:

 Financing Preference:

Loan                              Subordinated Debt     
Royalty Financing         Equity Position D Other

 Brief Description of Proposed Projects:

 Business plan:

Attached                       Available upon request  
Not completed

 Total Project Cost:

 Amount requested: