CONTACT INFORMATION

ENTITY INFORMATION

Entity Status:

Existing Entity

New (proposed) Entity

Changing Legal Entity of Existing Business That You Currently Own/Operate

Other

Please Describe:

Current or Proposed Business Name:

Alternative Name:

(If first choice is not available)

Type of Business or Main Business Activity:

Type of Entity:

To Be Discussed

Limited Liability Company

C-Corporation

S-Corporation

General Partnership

Limited Partnership/LLP/LLLP

Non-Profit

Sole Proprietorship

Other

Explain:

State of Business Formation:

ENTITY ADDRESS

Street Address of Business:

City:

State:

Zip:

ENTITY CONTACT INFORMATION

Telephone:

Email Address:

Is the business mailing address the same as above?

Yes

No

Business Mailing Address:

Street Address, City, State, Zip

Website for Business:

Do you consent to The Dumbar Law Center, P.A. serving as the Registered Agent for your business?

Yes

No

Who will be serving as the registered agent for your business? Please identify the Florida address for the registered agent.

BUSINESS INFORMATION

Manager, Director or Other Officer #1:

If applicable, please select "Fill Out Manager/Director/Officer's Information" and list the following information.

Fill Out Manager/Director/Officer's Information

Name: Title: Address:

Street Address, City, State, Zip

Date of Birth:

Not Applicable

Manager, Director or Other Officer #2:

If applicable, please select "Fill Out Manager/Director/Officer's Information" and list the following information.

Fill Out Manager/Director/Officer's Information

Name: Title: Address:

Street Address, City, State, Zip

Date of Birth:

Not Applicable

Manager, Director or Other Officer #3:

If applicable, please select "Fill Out Manager/Director/Officer's Information" and list the following information.

Fill Out Manager/Director/Officer's Information

Name: Title: Address:

Street Address, City, State, Zip

Date of Birth:

Not Applicable

Manager, Director or Other Officer #4:

If applicable, please select "Fill Out Manager/Director/Officer's Information" and list the following information.

Fill Out Manager/Director/Officer's Information

Name: Title: Address:

Street Address, City, State, Zip

Date of Birth:

Not Applicable

INTENDED BANK AND EMPLOYEES

Name of Intended Bank:

Will you hire employees?

Yes

How many? When will you begin paying wages?

No

BUSINESS OWNER INFORMATION (Shareholders, etc.)

Business Owner #1:

If applicable, please select "List Business Owner" and fill out the following information.

List Business Owner

Full Legal Name: Address:

Street Address, City, State, Zip

Percentage of Ownership:

(or shares of stock)

SSN/Tax ID: Initial Contribution:

Not Applicable

Business Owner #2:

If applicable, please select "List Business Owner" and fill out the following information.

List Business Owner

Full Legal Name: Address:

Street Address, City, State, Zip

Percentage of Ownership:

(or shares of stock)

SSN/Tax ID: Initial Contribution:

Not Applicable

Business Owner #3:

If applicable, please select "List Business Owner" and fill out the following information.

List Business Owner

Full Legal Name: Address:

Street Address, City, State, Zip

Percentage of Ownership:

(or shares of stock)

SSN/Tax ID: Initial Contribution:

Not Applicable

Business Owner #4:

If applicable, please select "List Business Owner" and fill out the following information.

List Business Owner

Full Legal Name: Address:

Street Address, City, State, Zip

Percentage of Ownership:

(or shares of stock)

SSN/Tax ID: Initial Contribution:

Not Applicable

Business Owner #5:

If applicable, please select "List Business Owner" and fill out the following information.

List Business Owner

List Business Owner Address:

Street Address, City, State, Zip

Percentage of Ownership:

(or shares of stock)

SSN/Tax ID: Initial Contribution:

Not Applicable

Important Information for Any Additional Business Owners.

PROFESSIONAL ADVISORS (Accountants, Lawyers, etc.)

Professional Advisor #1:

If applicable, please select "List Professional Advisor" fill out the following information.

List Professional Advisor

Name: Type of Role: Phone: Address:

Street Address, City, State, Zip

Not Applicable

Professional Advisor #2:

If applicable, please select "List Professional Advisor" fill out the following information.

List Professional Advisor

Name: Type of Role: Phone: Address:

Street Address, City, State, Zip

Not Applicable

Professional Advisor #3:

If applicable, please select "List Professional Advisor" fill out the following information.

List Professional Advisor

Name: Type of Role: Phone: Address:

Street Address, City, State, Zip

Not Applicable

Professional Advisor #4:

If applicable, please select "List Professional Advisor" fill out the following information.

List Professional Advisor

Name: Type of Role: Phone: Address:

Street Address, City, State, Zip

Not Applicable

CAPITAL/FUNDING

With what assets do you plan to fund the business with initially?

Have you taken out any loans to pay for startup costs of the business?

Yes

Please describe the nature of the loan and identify the institution that holds the loan.

No

ADDITIONAL INFORMATION

Do you have a business plan?

Yes

Please Describe: Please attach, if available.

Add attachment

Add attachment

Choose file

This file could not be attached because it exceeds the 50MB limit.

Please choose a file.

Cancel Upload

No

Will the business use trademarks or logos?

Yes

Please Describe: Upload a copy of your logo or trademark.

Add attachment

Add attachment

Choose file

This file could not be attached because it exceeds the 50MB limit.

Please choose a file.

Cancel Upload

No

Do you own any real property related to the business?

Yes

Please provide the deed.

Add attachment

Add attachment

Choose file

This file could not be attached because it exceeds the 50MB limit.

Please choose a file.

Cancel Upload

No

Do you intend to offer employees/consultants equity-based compensation incentives?

(e.g. stock options, profits interests, etc.)

Yes

Please Describe:

No

Will the business require any special licenses?

(i.e. liquor, gambling, etc.)

Yes

Please Describe:

No

Does the company have a written or oral business succession plan?

Yes

Please Describe:

No

Has the business ever been formally valued through a business evaluation?

Yes

Date of Valuation: Entity That Completed Valuation: Amount:

No

Amount the owners believe the company is currently valued at?

E-ACKNOWLEDGEMENT AND ACCEPTANCE:

I affirm and acknowledge that all of the above information is true and accurate to the best of my knowledge.

Printed Name: Date:

THANK YOU