Interest Form

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Where Are You Located?

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How Did You Hear About Us?

Tell Us A Little Bit About Your Business

Why Are You Passionate About Your Business?

What Are Your Most Immediate Challenges?

How Important Is It For You To Reach Your Capital Raising Goal In The Next 6 to 12 Months?

Not Important

Somewhat Important

Important

Very Important

Extremely Important

Which Of These Best Describes The Stage Of Your Business?

It's just an idea.

I have a clear plan, but I don't have any revenue yet.

I have some revenue but am still in the early stages.

I have steady revenue but have never made a profit.

The business is profitable, and I want to grow it to the next level.

Are You Interested In Raising Capital With Investment Crowdfunding?

Definitely

Maybe

I Need More Information

Is There Anything Else You Would Like Us To Know?

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