Sample Page

Contact Name

Spouse/Partner Name



Postal / Zip Code


How long have you lived at this address?

Phone Number


Spouse/Partner Email

Citizenship Status


List all dependents as represented on your tax filings


List all dependents as represented on your tax filings

Upload Resume/CV (Optional)

Upload Photo (Optional)

Business Background

Tell us a little about your business experience

Present Employer



Length of Employment

Annual Salary

Will you be leaving this employment to open your business?

Any other source of income?

Total Combined Income

Have you ever owned your own business?

What type of business?

How long operated

How did you become interested in this business? *

Have you ever managed employees?

If so, at what capacity?

When would you like open?

Whats your primary reason(s) for going into your own business?

What would you consider your strengths in owning your own business?

What would you consider your primary concerns in owning your own business?

In which geographical area would you like to open your business?

Will you be opening this business with a partner?

If so, will this partner be active?

What languages do you speak?

Financial Information


Basic financial asset information

Cash on Hand & In Banks

Stocks, Bonds & Securities

Retirement Funds

Loans owed to you (Due w/in 1 yr)

Do You Own or Rent Your Home?

Real Estate: (present value)

Businesses Owned

Any other assets


Basic liability infomation

Notes payable to Bank

Notes payable2 to individuals

Total credit card debt

Vehicle Loans

Home Mortgage

Other Mortgages

Student Loans

Any other debts

Net Worth:

Assets minus Liabilities

Total Assets

Total Liabilities

Assets - Liabilities = Net Worth

Amount of Capital to Invest

Source of Capital