Contact Information:

1. Indicate the industry group your company will compete in (check all that apply).

Aerospace
Agriculture/fishing/forestry
Biotechnology
Broadcasting/cable/radio
Chemical and materials
Computer Hardware/Software
Consumer Goods
Defense/Governmental
Education
Energy and natural resources
Entertainment/recreation
Environmental - includes waste
Financial services/banking/insurance
Food services/products
Import/Export
Information services/products
Manufacturing
Medical/Health
Publishing
Real estate and construction
Retail - includes stores and restaurants
Services
Telecommunications
Transportation
Other

2. Indicate the SIC Code (click here for a list) that best describes your industry group.

3. How much investment capital do you require?

4. Please indicate the stage of funding desired.

Make Selection Seed Startup Development Expansion Growth Acquisition Project Financing International Trade Financing

5a. How much investment capital has management actually raised for the company?

5b. Sources:

Make Selection Friends Banks Savings SBA Venture Capitalists Private Placement Direct Public Offering Individual Investors SCOR Offering Asset Based Lender Accounts Receivable Financing Equipment Leasing Other

6. How long has management been actively seeking to raise investment capital?

Make Selection 1 month 3 months 6 months 9 months 12 months 15 months 18 months More than 24 months

7. How would you describe the financial condition of the company?

Make Selection Excellent Good Fair Poor

8. Do you have a Business Plan? Yes No

9. When was your business plan last updated?

Make Selection 1 month 3 months 6 months 9 month 12 months More than 12 months

10. What category best describes the operational status of your company?

Make Selection Venture Evaluation - Pre Incorporation Startup Breakeven On Going Concern - Profitable On Going Concern - Not Profitable Business Opportunity

11. How long has the company been in business? years

12. What is the legal structure of the company?

Make Selection Pre-Organization Sole Proprietorship LLC LLP General Partnership S Corporation C Corporation Limited Liability Corporation

13. How much capital has the company spent on marketing the company to potential investors and/or the financial community?

14. What form of investment is management seeking?

15a. What are your YTD gross sales?


15b. What are the total assets of the company?


16. How much equity is management prepared to offer? %

17. Does the company need assistance in any of the following areas? Check all that apply.

Strategic Planning
Management Consulting
Investor Relations
Financial Advisory
Investment Banking
Business Plan Evaluation/Review

18. Has the management or the company been involved in any litigation or filed for bankruptcy protection in the past five years? Yes No

If yes, Please explain:

The Company

A brief but specific description of the venture, including current status, ownership, key goals and objectives.

Product or Service Description

Uses and applications of your firm's product or service, including major features, benefits to users, proprietary advantages and present stage of development.

Market

Describe your target market, its size in terms of units and dollars, current and projected market share and current
and projected geographic market. Also, describe your competition (list major competitors by name and market share).

Management

Describe the qualifications of the management team. If the team is not not in place, describe the attributes of
the ideal candidate for each key position.

Financial Summary

Show the company's financial performance in terms of revenues, expenses and net profit for the past two
years (if applicable). Also, forecast the company's financial performance for three to five additional years.

Investment Requirements & Exit Strategy

Describe the amount and sources of capital invested in the company to date, including cash and non-cash
investments. Additionally, indicate how the invested capital is to be used (i.e. how much of the required
investment is needed for sales and marketing, working capital, equipment, research and development,
retirement of existing debt, etc.) Indicate if investors will be secured, the expected return on investment,
and describe your exit strategy (including time frame) for investors.

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