Capital Raise Application

Contact Details

Your Name *

Your Email *

Your Contact Number *

Business Profile

Business Legal Name *

City *

State *

Zip *

Business Telephone Number *

Business Email Address *

Web Address *

My company's run rate is currently or has a run rate on track to surpass $1M Revenue in the next 12 months *
Last 12 months revenue < $500,000Last 12 months revenue > $500,000 but < $1,000,000Last 12 months revenue > $1,000,000 but < $2,500,000Last 12 months revenue > $2,500,000

Years in business? *
less than 1 Year1 to 5 Years5 Years+

State of Incorporation? *
Please Select a StateNot ApplicableAlabamaAlaskaArizonaArkansasAmerican SamoaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasTrust TerritoriesUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming

Type of Business Entity * Sole ProprietorshipPartnershipLimited Liability Co.CorporationOther

if ticked other:

Capital Request

Current Fundraising Target ($) * $2M-5M500K-2M100-250Kunder $100K

Additonal Comment:(100 character Limit)

Purpose * Working Capital / Cash Flow NeedsMergers & AcquisitionsPurchase / Refinance EquipmentInventory FinancingOther

Other:(500 character Limit)

By what date are you aiming to close the funding round? *

If equity, at what valuation are you looking to raise capital at? ($)

Do you want guidance on growing your business? * YesNo

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