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FINANCIAL INSTITUTION/INVESTOR REGISTRATION FORM

Complete this form to be notified of financing opportunities that meet your financing criteria.



1. Contact Information

Name
Title
Company
Street Address/ Suite Number
City
State/Province Zip/Postal Code   
Country
Telephone
Facsimile
Email Address

2. Type of Institution

Investment Group
Venture Capitalist
Broker/Dealer
Bank
Asset Based Lender
Institutional Investor
Accounts Receivables Factor
Medical Receivables Factor
Pension Fund
Mutual Fund
Other, Please specify:


3. Service Offering/Description

A. Describe services offered by your company:

B. Indicate the type and stage of funding provided by your firm (i.e., equity, debt, business loans for expansion, working capital, etc.) :

C. Geographic locations of interest (including international):

D. Specify your investment/funding criteria (i.e., industry group(s), sales, profitability, years in business, cash flow, etc.):

E. What size of investment or funding do you prefer: :
Minimum investment amount ($US)
Maximum investment amount ($US)

F. What are your fee arrangements?

G. Other comments, information, requests, instructions, etc:

Depress the "Submit" button to send this application to our processing center our call us at the toll free number below.


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Skelton Carter Hall & Company
100 Park Avenue, Suite 1600, New York, NY 10017

Telephone Number: (888) 617-0622
International Number: (001) 212-880-2682
Fax Number: (718) 732-2168