Date of Incorporation — must be incorporated at least 3 years ago

Industry / Sector*Retail & e-commerceHospitality & food serviceProfessional servicesConstruction & propertyManufacturingTechnology & softwareHealthcareTransport & logisticsWholesale & distributionOther

Number of Employees*1–56–1011–2526–5051–100100+

Preferred Repayment Term*Up to 12 months1–2 years2–3 years3–5 years5–7 years7+ years

Primary Purpose*Working capital / cashflowEquipment or machinery purchaseProperty acquisition or refurbishmentBusiness expansionHiring / staffing costsRefinancing existing debtStock or inventory purchaseMarketing or growth investmentManagement buyout / acquisitionOther

Urgency of FundingASAP (within 2 weeks)Within 1 month1–3 monthsNo particular urgency

Previous Finance Applications (last 6 months)NoYes — application pendingYes — declinedYes — offer received but not accepted

Director Date of Birth*

Years at this AddressLess than 1 year1–2 years3–5 years5+ years

This director consents to a soft credit search being conducted for pre-qualification purposes.

I confirm the information provided is accurate and I am authorised to submit on behalf of the company.

I consent to this information being shared with relevant lending partners by Agema Partners.