Business Assessment Form    

In order for our staff to determine the viability of an investment in your venture, you will need to provide us with some basic information. This is the essential first step in determining our ability to help you to secure the capital you seek. Once we have received your information, we will contact you within 48 to 72 hours to discuss the details of your business. Please provide complete data. Any incomplete assessment forms will not be processed. Please include a day time phone number so that our staff may reach you during business hours.

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Please provide the following contact information:

Full Name
Organization
Comp. Affiliation   Principal    Broker     Other    
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX (Please include a fax# if possible-many investors prefer it)
E-mail (Triple-check for correct e-mail address!)
Website

How did you find out about the BRN website?         

If you found us in a newspaper, which one?  

Business Information:

Please identify your specific business type in the space provided below. (i.e. "Computer Software Manufacturer")


Select the industry that best applies to your business:

  

Please enter the amount of capital you seek:

$ (minimum amount must be $50,000)

Choose one of the following options that identify the financial stage of your business:


If applicable, what was last years gross sales figure?    

How much money do you have invested in this project?  

What is the maximum amount of equity you would offer?  %

Do you have a business plan?

Yes No        If no, are you interested in our business plan services?    Yes

Do you have an offering memorandum / subscription agreement?   Yes   No

What is (or will be) the legal structure of your business? 

Have you budgeted any funds for the purpose of raising capital?   Yes   No

How long have you been searching for funding?  

Please note any significant information for our consideration process.


    

Pressing the submit button more than once will create multiple submissions. Please be patient, slower computers may take a couple of minutes to process. If form times-out, then reset and re-submit. Thank you.

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Revised: October 16, 2000 1
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