Indicates Required Field
First Name
Last Name
Address 1
Address 2
City
State
Zip Code
Contact Telephone
Cell Phone
Email
Company Particulars of Interest Personal Details (All Information is Held Confidential)
1. Type of Business
No Particular - Private Investor
No Particular - Equity Investor Firm
Manufacturing
Service
Retail
Medical
Engineering
Mining
2. Cash Flow Requirements
3. Number of Employees
--- Please Select ---
1-10
11-50
50-100
>100
All
4. Own/Rent
--- Please Select ---
Own
Rent
All
5. Age of Business
--- Please Select ---
1-3
4-10
11+
All
Personal Details (All Information is Held Confidential)
1. Seriousness of Buying (10 highest)
--- Please Select ---
1
2
3
4
5
6
7
8
9
10
2. Investment Amount
3. Have You Owned a Business
--- Please Select ---
Yes
No
4. Have You Sold Business
--- Please Select ---
Yes
No
