PME Fund Application Form |
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Application Fee: Select 'Yes' if this fee has not been paid by another shareholder. (One fee per startup) The application fee is none refundable. | |
Credit Card Number | |
Card Type | |
Cardholder's Name | As it appears on your Credit Card |
Expiry Date | | / | |
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Verification Number | The Verification Code is a three-digit number on the back of your Visa or Mastercard credit card |
Billing Address | |
City | |
Province | |
Postal Code/Zip | |
Application Fee | $250.00 |
Amount requested: $ | |
Purpose: | |
Operating: $ | |
Leaseholds: $ | |
Equipment: $ | |
Other: $ | |
Details regarding purpose of the investment: | |
Full legal name: | |
Trade name: | |
Address | |
City | |
Province | |
Postal Code/Zip | |
Phone (Bus.) | |
Phone (Fax) | |
E-mail | |
Company url, if any | |
LinkedIn account | |
Twitter account, if any | |
Facebook page, if any | |
Describe your company in 50 characters or less. | |
If you have an online demo, what is the url? | (Please don't password protect it; just use an obscure url.) |
Business start-up date | | / | | / | |
(yyyy/mm/dd) |
Fiscal year end: | | / | |
(dd/mm) |
Principal owner: | |
Ownership: | |
Role/function: | |
Full time: | |
Have you ever submitted an application with ProMontreal Entrepreneurs? | |
please indicate the year and the business name. | Failure to do so, will result with your application not being given any further consideration. |
Is there an another principal owner?: | |
Principal owner 2: | |
Ownership 2: | |
Role/function 2: | |
Full time: 2 | |
Is there an another principal owner?: | |
Principal owner 3: | |
Ownership 3: | |
Role/function: 3 | |
Full time: 3 | |
Has your business ever filed for bankruptcy or defaulted on any debts? | |
Is your business a party to any claim or lawsuit? | |
Has this business guaranteed the financial commitments of others? | |
Are any taxes (GST, QST, business, real property) in arrears? | |
If “yes” to any of above, please provide details. | |
First Name | |
Last Name | |
Maiden name: | |
Address 1 | |
City | |
Province | |
Postal Code/Zip | |
Phone (home) | |
Phone (cell) | |
Marital status: | |
No. of dependent children: | |
Birth date: | | / | | / | |
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Company | |
Position: | |
Salary per annum: | |
Start date: | | / | | / | |
(yyyy/mm/dd) |
Address 1 | |
City | |
Province | |
Postal Code/Zip | |
Province | |
E-mail | |
First Name | |
Last Name | |
Maiden name: | |
Company | |
Position: | |
Salary per annum: | |
Start date: | | / | | / | |
(yyyy/mm/dd) |
Address 1 | |
City | |
Province | |
Postal Code/Zip | |
Phone (Bus.) | |
E-mail | |
Personal Balance Sheet as of: | | / | | / | |
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Deposits: | |
Cash: | |
Term deposit: | |
Mutual funds: | |
Stocks: | |
RRSPs: | |
Residence: | |
Real estate: | |
Vehicle: | |
Other (please specify): | |
Total Assets: | |
Mortgage(s): | |
Loans: | |
Credit cards: | |
Personal line of credit: | |
Other (please specify): | |
Total Liabilities: | |
Total Assets minus Total Liabilities: | |
Gross monthly income: | |
Spouse’s gross monthly income: | |
Other $ (please specify): | |
Total Income: | |
Mortgage: | |
Property taxes: | |
Loan payments: | |
Credit card payments: | |
Support payments: | |
Rent: | |
Other: $ | |
(Please specify): | |
Total Expenses: | |
Have you ever filed for bankruptcy or defaulted on any debts? | |
Are you a party to any claim or lawsuit? | |
Have you personally guaranteed the loans or financial commitments of others? | |
Are any taxes (GST, QST, business, real property) in arrears? | |
If “yes” to any of above, please provide details. | |
Name of Applicant | |
Acceptance | |
Date | | / | | / | |
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Business Plan | Upload file should be in one of the following formats: JPG, GIF, PNG, PDF, DOC, DOCX The file should not exceed 10MB |
Financials | Upload file should be in one of the following formats: JPG, GIF, PNG, PDF, DOC, DOCX, XLS, XLSX The file should not exceed 5MB |
CV | Upload file should be in one of the following formats: JPG, GIF, PNG, PDF, DOC, DOCX The file should not exceed 5MB |
Letters of recommendation | Upload file should be in one of the following formats: JPG, GIF, PNG, PDF, DOC, DOCX The file should not exceed 5MB |
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