Untitled Document

Your Name:
Company Name:
Your Position:
Street Address:
City:
State:
Zip Code:
Country:
Phone Number:
Fax Number:
E-Mail Address:
Web Site URL:
What is your primary product or service?

How much financing have you received in the last 18 months?

Common shares issued & outstanding:

Preferred shares issued & outstanding:

Number of shareholders currently (approximately):

Approximate Revenues (this year):

Last Year's Revenues:

Next Year's Revenues:

Approximate Annual Net Earnings:

Approximate Total Assets:

Management Experience:

If you are a consultant, tell us about your business:

What is your time frame for going public?

Strategic relationships with other corporations:

Why do you want to go public?

Miscellaneous Information (feel free to cut and paste your executive summary)


Thank you for completing this form and/or sending us additional information. We look forward to learning more about your company.

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