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 Business Name :
Tel :
Web:
Mobile :
Name of main shareholder and the Borrower:
Name of Authorized underwriters/Signature:
Resume shareholder and the Borrower:
Name & Resume Authorized underwriters/Signature:
Number of years Management experience in the field :
Length of time seeking capital for the current project :
Kind of Business:
Address: City
State/Country: Zip: Phone: Email
Name of principal : Your Title:
Approximate Credit Score:
Please select Investment Request type.
(Private Equity or Joint Venture or Private Debt
Or loan or other)
Funding/Loan Amount Requested: $ Approximate Net Worth/acquisition: $
Period of repayment :
How to Finance :
Own : Other Investment need:
Liquid Assets (Cash on hand): net worth :
Hard Fixed Assets (Currently fully owned:

2. Collateral available :
Purpose of the acquisition financing / request:
Asset description
Asset description:
Purchase? ___Yes ___No
Purchase Price? Down payment: $
Property condition:
Any history:
Occupancy:
Performances:
Operating history of applicant. In(Millions –US$) 2011 2012 2013
Gross
revenue
EBITDA
Net
worth
Going Forward Performa (Millions-US$) 2014 2015 2016
Gross
revenue
EBITDA
Net
worth
You must attach: Financial Statement & Asset Liability without it we will not able to proceed
Signed by applicant
Print name
Position
Date