General Information:
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| Officer Name: |
A value is required. |
| Title: |
A value is required. |
| Corporate Name: |
A value is required. |
| Address: |
A value is required. |
| Address 2: |
A value is required. |
| Phone: |
A value is required. |
| Fax: |
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| Email: |
A value is required. |
| Business Background & Industry: |
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| Objective for Acquisition: |
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Specific Business Request
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| Industry: |
Retail
Manufacturing
Distribution
Service
Other
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| Preference |
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| Rank: |
NAICS Classification code(s) |
| 1) |
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| 2) |
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| 3) |
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| 4) |
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| 5) |
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| Preferred Location of Business: |
A value is required. |
| Amount of Funds to be Committed: |
A value is required. |
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| What is the Acquisition Timing?: |
A value is required. |
| Optimum Revenue of Target Company: |
A value is required. |
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| Amount of Pre-Tax Earnings EBITDA: |
A value is required. |
| Annual, Return on Investment |
A value is required.% |
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| If there are Partners/Investors, Their Names and Involvement are: |
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| Name: |
Involvement: |
| 1) |
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| 2) |
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| 3) |
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| Do You Need any Other Approval(s) to Make the Decision to Purchase?: |
Yes l No |
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| If Yes, What is Their Name and Relationship?: |
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| Name: |
Relationship: |
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| If a Bank is Involved, has a Contact Been Made? |
Yes l No |
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| Name of Bank: |
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| Loan Officer: |
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| Location of Bank: |
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| Phone #: |
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| A value is required. |
A value is required. |
| Signature of Corporate Representative |
Authorized Officer |
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