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.)
Primary Mailing Address:
Physical Business Address(es) (if different from mailing address):
Name of CEO or Executive Director:
CEO or Executive Director Phone:
CEO or Executive Director Email:
Amount Requested (in USD):
Debt or Equity? (Choose one.)
Additional Notes (if applicable):
Percentage of the Company Offered in Exchange for MNTR’s Investment:
Please review this form carefully before submitting.
I declare under penalty of perjury 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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