Public WIF GVC Form

First Name of Request Filer

Last name of Request Filer

Multi-line address

Country/Region

Address

City

Zip / Postal code

Company or Companies Headquarters Location, or proposed headquarter(s) location(s). [At least city and state/province and country.]

Phone

Position(s)

Profession and/or Occupation

Current or former, and please state if unemployed?

Company Name(s) and/or (if starting a business or businesses) Proposed or Tentative Company Name(s)

Amount or range amount of money of venture capital financing being requested in this request?

Highest Percentage Stake(s) or range of stake(s) in company or companies willing to sell for venture capital financing from this request?

Actual or Estimated Ownership percentage stake(s) already currently owned by owner(s) in company or companies in this request and/or to be owned in proposed company or companies?

Amount of net income per year or projected amount of net income per year of company or companies in this request?

Unofficial Current Value of Company or Companies in this request?

Industry or Industries of Company or Companies in this request?

Description of how do you plan to use the venture capital financing?

For example, please state if you plan to use the financing on purchasing an existing business, new equipment or other property, hire employees, renovate, or expand into a new location etc., or whatever the case maybe.

Estimated Per Annual Net Income Per Year?

Estimated Personal Current Net Worth?

Personal Statement (in support of and why you should receive government funding through WIF for this venture capital financing request)

For instance, please include any difficulties in obtaining other financing other than through WIF, in obtaining and maintaining a decent job, or other life hardships, or whatever the case maybe.

Highest Educational Level Degree Completed

If none, put N/A.

Are you a student?

If so, at which school(s), at what grade level(s), year(s), or number of semester(s)?

Are you an alumni of any school?

If so which one(s)? If graduated what year?

Major(s) of Completed Educational Degree(s)

If no degree, put N/A.

Are you a current or former elected or appointed government official?

If so which jurisdiction(s)? Position(s)?

Resume

Veteran Status (Optional)

Are you a military veteran?

Are you a current or former member of the Armed Forces of a country? (Optional)

If so which branch(es) current and/or former, which country(s)?

Are you a public safety member? For instance, law enforcement, firefighter, corrections, or emergency medical services (ems)? (Optional)

If so which one(s)? Position?

Disability Status (Optional)

Are you disabled? If so what disability or disabilities?

Race (Optional)

Sex (Optional)

National Origin (Optional)

Age (Optional)

Religion (Optional)

Marital Status (Optional)

Number of Children (Optional)

Please specify for each, if different, how many biological, how many foster, how many adopted, and any grandchildren if any?

Language(s)(Optional)

Political Affiliation (Optional)

Sexual Orientation (Optional)

Optional File upload (Please upload any document(s), business plan(s), financial statement(s), and/or other information you would like us to consider in this request.

Signature- You hereby certify that the information you have provided in this form is true and correct to the best of your knowledge and belief.

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Message (Optional) including any clarifications.

World Investment Fund

"Saving Lives Through Good Works"

Public WIF GVC Form