Application Form

Gross Revenue by Type of Businesses Sold

What types of businesses are you selling? Please use the next 4 sections to select all businesses that apply. If the types of industries you are brokering exceeds 4, then indicate that in the notes section below the "4th Business Sold" section.

1st Business Sold

Category 1

Transactions Past Year

Revenue Past Year

Transactions Current Year

Revenue Current Year

2nd Business Sold

Category 2

Transactions Past Year

Revenue Past Year

Transactions Current Year

Revenue Current Year

3rd Business Sold

Category 3

Transactions Past Year

Revenue Past Year

Transactions Current Year

Revenue Current Year

4th Business Sold

Category 4

Transactions Past Year

Revenue Past Year

Transactions Current Year

Revenue Current Year

If the types of industries you are brokering exceeds 4, then take this section to explain further:

Historical Gross Revenues

Let us know what your business brokerage accrued in the last 3 years with annual sales, commissions, & other fees.

Year (A)

Amount

Year (B)

Amount

Year (C)

Amount

List the percentage of revenues from the following transaction types

Commissions

Flat Fee

Other

Average/Maximum Value of Transaction

Average Deal Value *

Maximum Deal Value *

Do you work with individuals with assets over $1,000,000? *

YesNo

Applicant is a/an *

CorporationPartnershipIndividual

Does the Applicant ever function in a dual intermediary agent function? *

YesNo

Describe Procedures to avoid financial statement misrepresentation when presenting business financials to potential buyers *

Does applicant prepare a broker’s reconstruction of financial statements?

Does Applicant conduct any business valuation or due diligence on behalf of the buyer or seller?

Does applicant provide written recommendations that each party retain an attorney and accountant for purpose of performing due diligence review, including an evaluation of income, expense, and feasibility of the business opportunity represented? *

YesNo

Number of partners, principals, officers, and professional employees engaged in providing professional services to clients *

Number of non-professional service employees: *

Is the applicant firm controlled, owned or associated with any other firm, corporation or company? *

YesNo

If Yes, please describe the relationship

Please provide the following information on key employees, principals, partners

Fill out as many sections that apply

Name in Full of Key Employee 1

Professional Qualifications

Date Qualified

How long in practice?

How long partner/principal?

Name in Full of Key Employee 2

Professional Qualifications

Date Qualified

How long in practice?

How long partner/principal?

Name in Full of Key Employee 3

Professional Qualifications

Date Qualified

How long in practice?

How long partner/principal?

Name in Full of Key Employee 4

Professional Qualifications

Date Qualified

How long in practice?

How long partner/principal?

What professional associations does the applicant belong to?

Please list five largest deals in past three years

Project/Deal/Name *

Nature of the services *

Revenue obtained *

Project/Deal/Name

Nature of the services

Revenue obtained

Project/Deal/Name

Nature of the services

Revenue obtained

Project/Deal/Name

Nature of the services

Revenue obtained

Project/Deal/Name

Nature of the services

Revenue obtained

Does the applicant use a written contract with the client? *

In All CasesSometimesNever

What percent of applicant’s business involves subcontracting of work to others?

Do you have similar insurance in place?

YesNo

Have you had any claims on insurance in place?

If you have had any claims in the past, or been subject to disciplinary action by authorities as a result of professional activities please describe below

One Signature to Safety