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Seeking Venture Capital Enquiry

Use this form if you are seeking barter venture capital

Your Details

First Name:

Last Name:

Your Contact Information

Personal Email:	Other Email:
Skype:	MSN:	QQ:
Phone:	Mobile:	Fax:

Address:

Postal Address:

Country:

Region:

City:

Investment Information

Amount Seeking:

Industry:

Development Stage:

Concept/Idea	Start-up	Prototype	Product Launched	Revenue Stage
Break-Even	Profitable

Provide a brief overview of your idea / product / service:

What makes you think that you will be successful?

Do you have financial forecasts to show the potential investor?

Yes

Do you require help with creating a forecast?

Yes

Do you have a business plan to show the potential investor?

Yes

Do you require help with creating a business plan?

Yes

Directors

First Name:		Last Name:		Age:
Address:

First Name:		Last Name:		Age:
Address:

First Name:		Last Name:		Age:
Address:

Percentage of company owned by current Directors:

Shareholders & Employees

How many shareholders do you have?
How many employees do you have ?
Percentage of company owned by current Shareholders:

Investment Use

What will you use the barter investment for? (.e.g. printing, advertising, office rent, accounting, legal services etc)

What percentage of the company are you willing to give up for this investment

What other requirements do you have of the incoming investor? (e.g. Knowledge in the area? Contacts in the same industry? Assistance with marketing? Do you wish them to sit on the Board of Directors or not?)

I, the undersigned, hereby submit the following application to the Ormita Commerce Network Board and/or their authorised Licensees and/or Affiliates (“Ormita”). I certify that all information, representations, or statements provided to Ormita in connection with this application are true and correct in all material aspects.

I understand this application is subject to final approval by Ormita and am aware that the investment credit available for investments is not available until final Ormita Board approval is secured.