Confidential Individual Buyer Questionnaire

BUSINESS INTERMEIDARY SERVICES, LTD.
1 WEST PACK SQUARE, SUITE 507, ASHEVILLE, NC 28801
PHONE (828) 285-0018 · FAX (828) 285-0071

CONFIDENTIAL INDIVIDUAL BUYER QUESTIONNAIRE

This questionnaire is to be used by high net worth individuals. Print out form and return to BUSINESS INTERMEDIARY SERVICES, LTD. Public and private companies and private investment groups use the CONFIDENTIAL CORPORATE BUYER QUESTIONNAIRE.

CONTACT INFORMATION

Date:_______________ Name: _____________________________________________

Address:_____________________________________ City:______________________ State: _____ Zip: ___________

Phone (home): (_____) ______________ Fax: (_____) ______________ Phone (business): (_____) ______________ E-mail ____________________________

BACKGROUND INFORMATION

Education: College(s) ______________________________Degree(s) _________________________________

Business Experience (check all that apply):

[ ] Sales	[ ] Marketing	[ ] Accounting	[ ] Retail
[ ] Engineering	[ ] Finance	[ ] Service
[ ] Marketing	[ ] Distribution	[ ] Operations
[ ] Other _________________________________________________________________

Industries:________________________________________________________________ Positions:________________________________________________________________
Present Employer: _________________________________________________________ Position:________________________________________ Salary: ___________________ Address:_________________________________________________________________
City:_____________________________ State:______ Zip: ____________
Do you presently own any business? [ ] Yes [ ] No
If yes, what type(s) of business(es)______________________________________________ ________________________________________________________________________
Approximate annual revenue(s): $____________________
If no, is this your first acquisition for your own portfolio? [ ] Yes [ ] No
Are you interested in acquiring less than 100% ownership? [ ] Yes [ ] No
Will you be an: [ ] Active Manager [ ] Passive Investor
How long have you been seeking acquisition?___________________
How soon is acquisition desired? ____________________________
Purpose for acquiring? ___________________________________________________________
Are you the sole buyer / investor? [ ] Yes [ ] No If no, how many others? ________
Please provide information and resumes for all investors.

Name:______________________________	Name:_____________________________
Address:____________________________	Address:___________________________
City:_______________________________	City:______________________________
State:___________ Zip: __________	State:__________ Zip: _________
Phone: (_____)_________________	Phone: (_____)_______________
[ ] Active Manager [ ] Passive Investor	[ ] Active Manager [ ] Passive Investor

FINANCIAL INFORMATION

Combines net Worth of all investors: $_________ Amount of investment equity available: $_________

List and describe all cash sources:_____________________________________________________

BALANCE SHEET (current as of:_______________ )

ASSETS and LIABILITIES:

Cash	$______________	Notes Payable	$______________
Securities	$______________	Accounts Payable	$______________
CD’s / Treasury Notes	$______________	Mortgages	$______________
Real Estate	$______________	Other Loans	$______________
Receivables	$______________	Other Liabilities	$______________
Other	$______________	Total Liabilities	$______________
Total Assets	$______________	Net Worth	$______________

FINANCIAL REFERENCES

Financial Institution: _________________________________________.Address:___________________________________________________
City:_____________________________ State:________ Zip: ________________
Contact Person: _____________________ Title:_______________ Phone: (_____)_____________
Lending Source :____________________________________________ Address:___________________________________________________
City:_____________________________ State:________ Zip: ________________
Contact Person: _____________________ Title:________________ Phone: (_____)____________

I certify that the above information is complete and accurate as of the date of this document and I authorize you to verify such information through reference and credit checks.

Signature: _______________________________________ Date: ________________

ACQUISITION CRITERIA

Description of Business(es) Sought:___________________________________________________.Geographic Preference Regions:___________________________________________________ Cities:___________________________________________________
Revenue Range: $_______to______million Transaction Value: $_______to_______ million Minimum Pre-Tax: $___________Minimum Cash Flow: $__________
Some of our businesses are actively operated by their current owners who would have to be placed.
Are you interested in a full-time operator type business? [ ] Yes [ ] No
Are you willing to relocate? [ ] Yes [ ] No

SIC Codes of Interest: Please circle the SICs which accurately reflect your specific areas of interest.

MANUFACTURING	WHOLESALE TRADE
20 Food and Kindered Products	50 Wholesale Trade - Durable Goods
21 Tabacco Manufacturers	51 Wholesale Trade - Nondurable Goods
22 Textile Mill Products	RETAIL TRADE
23 Apparel and Other Textile Products	52 Building Materials and Garden Supplies
24 Lumber and Wood Products	53 General Merchandise Stores
25 Furniture and Fixtures	54 Food Stores
26 Paper and Allied Products	55 Automotive Dealers and Service Stations
27 Printing and Publishing	56 Apparel and Accessory Stores
28 Chemical and Allied Products	57 Furniture and Home Furnishing Stores
29 Petroleum and Coal Products	58 Eating and Drinking Places
30 Rubber and Miscellaneous Plastic Products	59 Miscellaneous Retail
31 Leather and Leather Products	SERVICES
32 Sand, Clay and Glass Products	70 Hotel and Other Lodging Places
33 Primary Metal Industries	72 Personal Services
34 Fabricated Metal Products	73 Business Services
35 Machinery, Except Electrical	75 Automotive Repair, Services, & Garages
36 Electrical and Electronic Equipment	76 Miscellaneous Repair Services
37 Transportation Equipment	78 Motion Pictures
38 Instruments and Related Products	79 Amusement and Recreation Services
39 Miscellaneous Manufacturing Industries	80 Health Services
TRANSPORTATION, COMMUNICATIONS, ELECTRIC, GAS & SANITARY SERVICES	81 Legal Services
41 Local and Interurban Passenger Transit	82 Educational Services
42 Trucking and Warehousing	87 Engineering, Accounting and Related Services
44 Water Transportation	88 Private Household
45 Transportation by Air	89 Miscellaneous Services
46 Pipe Lines
47 Transportation Services
48 Communication
49 Utility Services

Additional space is provided for any 4-digit SIC codes you wish to specify: __________________________
Please provide any additional comments related to your acquisition needs or strategy that would give added insight to selecting acquisition candidates for your consideration.