Copyright 1997
All Rights Reserved
Effective: 3/1/97
Antenucci Financial Company
Mr. Mario Antenucci
3401-3 East Main Street
Endwell, N.Y., U.S.A. 13760
Telephone: 607-786-9238
Fax: 607-786-9239
Re: FUNDING PROJECT SUMMARY
Please be as complete as possible. This data will be used by our Capital Providers as a quick overview of your project’s needs. ALL information is kept Confidential. By completing this form you are under no obligation. Please print out this form and then type or neatly print all information.
REFERRAL INFORMATION
Full Name: Mario Antenucci Business Name: Antenucci Financial Company
( Note: This Referral Section has been completed by the Antenucci Financial Company. )
Address: 3401-3 East Main Street City: Endwell
State: New York Zip code: 13760 Telephone: 607-786-9238 Fax: 607-786-9238
CLIENT INFORMATION
Client’s Name:_________________________ Type of Business:
____________________________________________________________________________ Business Name:____________________________________________________________ Years in Business:__________________________________________________________
Geographic Region: ___ Northwest ___ Southwest ___ Northeast ___ Southeast ___ Midwest
___ West ( Central ) ___ East ( Central ) __ Canada __ Europe __ Overseas Current Capital Requirements:________________________________________________ Amount of Personal/Business funds to be invested:_________________________________ Use of Capital Proceeds (check all that apply):
__ Acquisitions __ Accounts Receivable __ Working Capital __ Inventory __ IPO __ Yacht
__ Sale Leaseback __ Car/Truck __ Investments __ Line of Credit __ Currency Acquisition
__ Oil & Gas Exploration __ Franchise Financing __ Business Start-up __ Joint Venture
__ Research & Development __ Construction __ Equity __ Mezzanine Financing __ Expansion
__ Leveraged Buy-out __ Other __________________________________________________________
__ Real Estate (Over $10 Million U.S.) __ Real Estate ($1-9 Million U.S.) __ Real Estate ($500K-1Mill)
__ Real Estate ($100,000-$500,000 U.S.) __ Real Estate (Under $100,000) __ Real Estate Development Real Estate Business Plan Available? __ Yes __ No Executive Summary Available? __ Yes __ No
Is or are the owners willing to provide personal guarantee(s)? __ Yes __ No Describe Collateral: _____________________________________________________________________
Does Client have knowledge of any specific funding problems? Check all that apply:
__ Bankruptcy - Personal (Owner/Partner) Chapter: ____ When Filed?______ When Discharged? ______
__ Bankruptcy - Business Chapter: ____ When Filed?______ When Discharged? ______
__ Loan Delinquencies ( in last 90 days )
__ Loan Delinquencies ( over 90 days )
__ Other Credit Problems: _______________________________________________________________
Does the Client hold seller-financed real estate or seller-financed business notes? __ Yes __ No Please indicate percentage of ownership that is available to investors, venture capitalists, etc.___________
