Gonen Capital Request Form

Legal Business Name

DBA / Trade Name

Entity Type

Business Address

Address Line 1

Address Line 2

City

State

Zip Code

Year Established

Primary Contact Person

Title / Role

Phone Number

Email Address

Website URL

Requested Capital Amount ($)

Target Closing Date

Primary Funding Pillar

Purpose of Funds (Brief overview)

Gross Annual Revenue (LTM) $

Average Monthly Revenue $

Current Net Income / EBITDA $

Existing Business Debt ($) $

For Real Estate Requests Only – Property Address

For Real Estate Requests Only – Estimated Value: $

Executive Project Summary & Growth Strategy

Please provide a high-level overview of the project, asset, or business scaling strategy this capital will deploy against:

Website Date Funding

Printed Name

Date

NPS National Press Service WiRE