Funding Evaluation Request

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10777 Westheimer Rd, Suite 1100, Houston Texas 77042 www.andicefunding.com
Free Funding Evaluation and Eligibility Request Form
Disclosure Statement

Your information will not be shared nor sold to any third parties. Please complete the form below to reserve a specific date and time for your participation in a free, no obligation funding evaluation. Note, any information provided to us will be held in strict confidence between our respective firms. We are not brokering your transaction nor will your contact information be provided to any third parties without your authorization. Further, your agreement to participate in a funding evaluation is not a commitment to fund your transaction or your company as no commitment for funding is made or implied by AIF unless in writing directly from AIF and or its affiliated capital partners.
Once the form below has been completed you will see a "thank you" page and we'll send you a confirmation email. Our confirmation email will be provided upon completion of this form. The confirmation will have a link to our internal library of documents, including a full FAQ and other downloadable PDF brochures. Should you not see our confirmation email, please check your spam folder.
Company Name*
Full Name*

First NameLast Name
Title*
Corporate Officers/ Principal Owners Only
Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Phone*

Area CodePhone Number
How did you learn of AIF?*
Who referred you to AIF?
Date company incorporated:*
What is your core business?*
Key product lines
What is the structure of your company?

Private CorporationPublicly TradedLLC or LLPNonprofitOther
What is the structure of your customers?

Privately OwnedPublicly TradedOur Parent or Holding CompanyNonprofitGovernment Agencies
Do you currently have contracts or transactions that need to be funded?*

YesNoIn the Bidding ProcessOther
Are your products sold globally?

YesNoNot yet
What type of funding are you seeking?*
What is the amount of your current funding needs?*

How would you rate your company's current debt to revenue ratio?

	1	2	3	4	5

1 is Worst, 5 is Best

Please use this space for additional comments:
Provide a brief overview for the use of funds requested.*
Enter the message as it's shown*
Should be Empty:

10777 Westheimer Rd, Suite 1100, Houston Texas 77042 www.andicefunding.com

Free Funding Evaluation and Eligibility Request Form

Disclosure Statement