AmeriFund Capital Group, LLC
2881 E Oakland Park Blvd. Suite 411
Ft Lauderdale, FL 33306
Phone: 888.615.8458 / (954) 941-2254
Fax: 954.537.3085

We will use our best efforts to secure a stock-collateralized loan on your behalf in accordance with the information you provide below. Your information will not be shared. We invite you to view our privacy statement.

Loan information -
Dollar amount you are seeking -
How long of a term?
Quantity of stock available -
Is your stock restricted / aged / free?		restricted   /   aged   /   free trading
If restricted, when is restriction lifted?
Date you need the funds available -
Contact information-
Name of borrower -
Residence address -
City -     State/Prov -     Zip/PostCode -
Residence phone -
Your company name -
Company address -
City -     State/Prov -     Zip/PostCode -
Business phone -
Business fax -
Cellular -
Your email address -
Preferred contact method -
Any  /   Email  /  Home phone  /  Business phone  fax  /  cellular
Stock Information-
Symbol -	Company -
Recent bid price -	Number of shares outstanding -
Current form of stock - certificate    /  electronic
Are you an - officer     /    director     /    shareholder  ?
Purpose -
Please provide a brief statement as to the purpose of the loan -
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