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.