| Applicant Information |
| Company Name: |
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| Address Street 1: |
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| Address Street 2: |
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| City: |
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| Zip Code: |
(5 digits) |
| State: |
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| Contact Information |
| Contact Name: |
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| Phone: |
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| Email: |
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| Transaction Information |
| Amount of Requested Bridge Loan: |
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| Purpose of Bridge Loan: |
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| Expected to be Repaid: |
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| Total Amount of New Capital (used to Repay Bridge Loan): |
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| Form of Capital: |
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| Expected Closing Date: |
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| Details on Form of Capital to pay off Bridge Loan:: |
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| Do you have a signed Term Sheet?: |
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| Assets to Pledge in Support of Bridge Loan?: |
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| Type of Assets to Pledge:: |
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| Company Financial Information |
| Industry:: |
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| How Long have you been in Business?:: |
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| Annuals Revenues: |
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| Any existing Bank or Credit Lines?: |
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| Is there a lien on your assets?: |
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| Are you in Default or Seriously Late with payments to Banks, Creditors, Tax Collector, others?: |
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| Do you have Two Years of Financial Statements available?: |
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| Any Pending LItigation or Judgments?: |
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| Check Here |
The above information has been submitted by an authorized company representative or broker consultant and is true and correct to the best of my
knowledge.
Upon clicking the 'Submit and Authorize' button below, Tortugas Finance Corp. or its agents are authorized to verify and investigate any and all
the above statements. |