1. Contact: Meir Gaon Phone: +972 522433520 Email: gaon11@orange.net.il
PRELIMINARY INFORMATION, KYC (Know Your Customer)
Date:__________ All sections must be completed- no empty lines.
Project /funding name:
Company BusinessName :
Tel :
Web:
Mobile:
Name of main shareholderandthe Borrower:
Name of Authorizedunderwriters/Signature:
Resume shareholderandthe Borrower:
Name & Resume Authorizedunderwriters/Signature:
Number of years Management experience in the field :
Length of time seeking capital for the current project :
Kindof Business:
Address: City
State/Country: Zip: Phone: Email
Name of principal : Your Title:
Approximate CreditScore:
Please selectInvestmentRequesttype.
(Private Equityor JointVentureor Private Debt
Or loan or other)
Funding/LoanAmountRequested:$ Approximate NetWorth/acquisition: $
Periodof repayment :
How to Finance :
Own: OtherInvestment need:
LiquidAssets(Cashonhand): networth :
Hard FixedAssets(Currentlyfullyowned:

2. Collateral available :
Purpose of the funding /financing / acquisition request:
Asset description
Assetdescription:
Purchase? ___Yes ___No
Purchase Price? Downpayment: $
Propertycondition:
Anyhistory:
Occupancy:
Performances:
Operatinghistory of applicant. In(Millions –US$) 2011 2012 2013
Gross
revenue
EBITDA
Net
worth
GoingForward Performa (Millions-US$) 2014 2015 2016
Gross
revenue
EBITDA
Net
worth
You mustattach: Financial Statement&Asset Liabilitywithoutitwe will notable toproceed
Signedby applicant
Print name
Position
Date