Personal Information:

 First Name:    Last Name: 

 Spouse First Name: 

 Address:  

 City:             State: AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY   Zip:

 Home Telephone:   Business Phone:

 Fax:         Email:

 Education

 Education (Self):              

 Special Training (Self):    

 Skills & Interests (Self):    

 Education (Spouse):           

 Special Training (Spouse): 

 Skills & Interests (Spouse): 

Work History (Self)

 Company:    Title: 

 Duties:      No. Years Employed: 

 Company:      Title: 

 Duties:      No. Years Employed: 

 Company:    Title: 

 Duties:      No. Years Employed: 

Work History (Spouse)

 Company:    Title: 

 Duties:      No. Years Employed: 

 Company:      Title: 

 Duties:      No. Years Employed: 

 Business Ownership (Self and/or Spouse)

 Business Name:     

 Location:            

 Number of Years Owned:     

 Disposition:        

Business Name:     

 Location:            

 Number of Years Owned:     

 Disposition:          

Financial Information - Annual Income

 Self $:  Spouse $:

Financial Interest

 Maximum Transaction Size $:

 Available Liquid Funds $: 

Collateral

 Home Value $:    Mortgage $:

 Other:

 Income Required after Debt Service $

 Other Pertinent Financial Information

 Estimated Net Worth:

Net Worth Statement Attached?Yes  No Will Deliver

Business Interests

  Desirable Interests:     

 Undesirable Interests: 

 Preferred Locations:   

 Unacceptable Locations: 

 Will you run the business?  Full Time   Part Time

   Level of Interest:      Very Interested    

                                Only if Opportunity is Good Fit.

 Interested in Turn Around Opportunities?  Yes  No

 Other Criteria: 

 Comments: