INFORMATION ABOUT YOU

Name __________________________________

Date of Birth____________________________

Home Address

____________________________

____________________________

____________________________

Business Address

____________________________

____________________________

____________________________

Home Phone Number ____________________________

Work Phone Number ____________________________

Other Phone Number ____________________________

Facsimile Number____________________________

E-mail Address____________________________

Web Site Address ____________________________

Have you ever declared bankruptcy, been accused, convicted or found liable for any violation of a federal or state securities law or regulation, or entered into a consent decree with, or had an injunction granted against you by, any federal or state enforcement agency or commerce department? __________(If yes, provide details)

INFORMATION ABOUT YOUR EMPLOYMENT

Present Employer____________________________

Employment Position ____________________________

How long have your worked there?__________

Do you intend to remain employed there? __________

If yes, for how long?__________

Did your current employer or any past employer require you to sign a noncompetition or confidentiality agreement? __________ (If yes, provide a copy of the agreement to your attorney)

Did you develop your business concept on company time or premises?__________

Did you use any company resources in developing your business concept?__________

If yes, what resources?______________________

Have you approached your employer with your business venture?__________

If yes, what was your employer's response?______________________

 INFORMATION ABOUT YOUR BUSINESS PARTNER(S)

(Your business partners, if any, should provide the same information you have provided above)

INFORMATION ABOUT YOUR BUSINESS VENTURE

Have you taken any steps to incorporate your business? __________(If yes, provide details)

Who is expected to initially own the business, in what percentages, and for what contributions?

Owner

Percentage of Ownership

Which of the owners are expected to be employed by the business? __________________

In what capacities? ________________________________________________________

For what compensation? ___________________________________________________

Are there any written contracts between the owners?__________ (If yes, provide your attorney with a copy)

Do you have a written Business Plan?__________ (If yes, provide your attorney with a copy of it)

Have you offered to sell or sold any interests in your business to any investors?_________ (If yes, provide details)

Have you obtained or sought to obtain any loans for your business?__________ (If yes, provide details)

Have you retained any consultants, accountants, or tax professionals?__________ (If yes, provide details)

Have you promised an interest in the company to any consultants?__________(If yes, provide details)

What assets does the business own?__________

Do you, any of your partners, or the business own any inventions the business intends to exploit?__________ (If yes, provide details)

Is the business a party or potential party to any joint venture, license, or similar agreement?__________ (If yes, provide your attorney with a copy)

Does the business have any trademarks or logos you wish to protect?__________ (If yes, provide details or renderings)

Does the business own or lease any real estate?__________ (If yes, provide details)

Does the business have any written financial statements?__________ (If yes, provide your attorney with a copy)

OTHER QUESTIONS

(Make a list of other pertinent questions to ask your attorney)