If you are a larger company looking for funding, please fill out this form:


Legal Name of Organization:

State of Incorporation:

DBA (if applicable):

Trading Symbol (if applicable):


Name of Owner(s) and Percentage(s) Owned Respectively:



(If more than 4 owners, list names and percentages in the "additional notes" section.)

Name:

Percent Ownership:

Name:

Percent Ownership:


Name:

Percent Ownership:

Name:

Percent Ownership:



Business Information:


Business Description:

Annual Sales:


Primary Mailing Address:

City:

State:

Postal Code:



Physical Business Address(es) (if different from mailing address):




Contact Information:


Phone:

Fax:

Mobile:

Email:

Name of CEO or Executive Director:

CEO or Executive Director Phone:

CEO or Executive Director Email:




Funding Request:


Amount Requested (in USD):



Additional Notes (if applicable):



Percentage of the Company Offered in Exchange for MNTR’s Investment:

Timeframe Requested:



Attachment:

Accepted formats: PDF, Word Doc

Attachment:

Accepted formats: PDF, Word Doc



Is your operation in legal compliance with local and state regulation?

Yes No I'm not sure



Please review this form carefully before submitting.

 I declare that the foregoing information is true and correct to the best of my knowledge. I authorize Mentor Capital, Inc. to verify the information contained herein.


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