Business Project Evaluation Registration & Inquiry Form

Use this form to enter information for the evaluation phase of your company or project, products, service or business proposal.

Registration Category

you may select more than one

Date this form is being filed (e.g., January 1, 1998)

** (required)

Social security number or other identifying number

Full name of person submitting this Registration (e.g John A. Smith)


Business or Company name if any:

Registrant's First Name:


Registrant' Last Name:


Middle Initial:

Email Address:


Internet Website Address

Street Address:


Additional Address:




Zip/Mailing Code (use12345 If no mail code):



Home Telephone #:

( )

Business Telephone #:

( )

Fax Number:

( )


Male Female


Your Role, Position, Office with this business or project:

What is the niche that this business or project fills that's likely to make it successful:

Describe when the project started and more details of your business aspirations and plans:

Describe any other business experience you have had:

What is the business form of your company or project (Sole Proprietorship, Corporation , LLC Partnership, other), explain which and who are the principal partners or shareholders with percentages:

List the current Management Team and their experience:

Is your product or service trademarked, patented or copyrighted, if so has there been independent evaluations of value:

Are you looking for manufacturing and/or distribution collaboration. Explain.

Have you, or are you interested in licensing your product or certain rights to it. Explain.

If your company is not a publicly traded company, are you interested in becoming a publicly traded entity. Discuss.

If your company is publicly traded already, are you interested in a capital or value infusion, or other assistance? Explain:

Explain how you market or plan to market you company, product or service:

What are the Assets of the Business? List with values:

What are the short & Long Term Liabilities of the Business? List with values:

Other Assets (Personal etc.) which may be used to collateralize the Business? List with values

Estimated funding needed. List purposes, major items and values:

Estimated time to self-sustaining operations. Explain:

Prior and current attempts at funding and results. Explain & list sources:

Type of Funding & Capitalization Interested in (Private Equity Buyout, Private Equity Offering, IPO, Merger / Reverse Merger, Hannaian Infusion, Secondary Public Offering, P.I.P.E., Bond Offering, Angel / Venture Capital, Bank / Debt Financing, Other), Prioritize & Explain:

How much revenue has the company or project generated in the past year if any, If none when do you expect to generate revenue, Explain:

Is there any cash available at this time to move the business/project forward.? If so how much, Explain:

What written documents do you have available related to the project (Business Plan, Prospectus, Contracts, Shareholders Agreements, Debt Obligations & Notes, Asset Ownership Documents, Deeds, Receipts, etc.)? List & Explain:

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