Basic Information:

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):

Debt or Equity? (Choose one.)

 Debt Equity

Additional Notes (if applicable):

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

Timeframe Requested:

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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