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Name:

City:

Home Phone:

Best daytime number to call:

How long have you been looking for a business?

Who, besides yourself, would be involved in this business?

Where would you like to be in business?

Street address:

Postal/Zip Code:

Other Phone:

Email Address:

What businesses have you looked at?

By when would you like to be in business?

Financial Information

Assets:

Cash in savings:

Value of home:

RSP's:

Other assets:

Cash in chequing:

Value of other real estate:

Value of business:

Liabilities:

Home mortgage:

Line of credit:

Other amounts owing:

Other mortgages:

Credit cards:

Net Worth:

Net worth: (assets minus liabilities):

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Date: