Assessment Application

Stonemark will hold this information Confidential during the Assessment, and will not share your identity with anyone until such time as, and only if, you engage our firm to represent you.

If you find this form too long, please feel free to sign our Guestbook and we will respond to you by phone.

For the assessment we require the information you provide be truthful and accurate to the best of your knowledge. But you agree it will not be revealed to anyone else including buyers or other brokers. Please provide as much information as possible. If some of it is not handy, leave it blank and we will discuss it with you later. It may take you up to an hour or more to complete this form. After completing the form, click the Submit Application button below. You can print this page to make a copy for your records.

Fields marked with * are required.

Business Information

Company Name *

Legal Structure *

Street Address *

Street Address

City *

State / Province *

Zip / Postal Code *

Country *

Phone # *

Area Code Number

Fax #

Area Code Number

Company Email

Company Website

Federal ID # *

Or enter unknown.

Personal Information

Prefix *

First Name & initial *

Last Name *

Suffix (Ph.D., CPA, etc)

Title

Home Address *

Home Address #2

City*

State / Province *

Zip / Postal Code *

Country *

Telephone #

Area Code Number

Facsimile #

Area Code Number

Email Address *

CONTACT: *
Where may we contact you? Indicate at least one address and one phone.

Work address Work Phone Home Address Home Phone

Company Information

DOMICILED *
Location of headquarters

STARTED *
Year company started

Estimate if unsure.

INDUSTRY: *
Describe the industry or market into which you sell products or services.

PRODUCTS/SERVICES: * Describe in general.

SIC:
Standard Industrial Codes (SIC) if known.

SEGMENT: *
Current area of business (Check all that apply.)

Wholesale	Manufacturing
Retail	Utilities
Finance	Real Estate
Services	Basic (agriculture, mining, etc.)

BRANDS: *
Describe products or brand names in specific. Indicate whether you manufacture and/or distribute.

CUSTOMERS: *
Describe and explain your customers by type. i.e.: consumers, manufacturers, etc. Only identify by name if any represent more than 5% of your volume or are of name significance.

TERRITORY: *
Describe the geographical territories you serve.

DISTRIBUTION AREA: *
Describe geographical area products and services are sold to. Please number in order of revenue. Leave blank if not applicable.

Global Regions:

U.S.	Canada
Europe	Asia
Central America	South America
Australia/New Zealand	Africa
India	All Regions

If U.S. or Canada, please specify states or provinces if other than "all":

COMPETITORS: *
Describe major and important competitors. Rank by sales volume if known, or estimate.

VENDORS: *
Describe large and important vendors and your current relationship. I.e., good, strained, etc.

FACILITIES: *
Please describe your buildings and equipment. Age, condition, locations, etc.

TRADE ASSOCIATIONS *
Industry trade Associations whether you are active or not. Please list in order of membership size.

TRADE MAGAZINES *
List all you know of.

Staff, Advisors & Owners

EMPLOYEES: *
Number and type of workers, i.e., clerical, blue collar, professional.

UNIONS: *
Do you have unions? If you answer Yes, please indicate names of unions.

MANAGEMENT: *
(# of Key professionals)

Past Financial Information

FINANCIAL: *
Describe your current financial situation. Cash flowing, borrowing situation, any imminent problems or challenges.

CREDIT: *
Describe your current credit reputation.

Financial
Statements

months Ending
(please use US dollars)

BALANCE SHEET *

Assets *

Liabilities *

Net Worth *

Adjusted Net Worth *
(if known)

INCOME STATEMENT*

Annual Revenue *

Cost of Sales *

Gross Profit *

Operating Expenses *

Net Income *