Name:
Title:
Function:	Private Investor Professional Investor Stock Broker Analyst Money Manager Hedge Fund Fund Manager Financial Institution Other
Organization:
Street address:
Address (cont.):
City:
State/Province:
Zip/Postal code:
Country:
Work Phone:
E-mail:
URL:
Service wanted:	Purchase or merger with Public Shell Private Placement Venture Capital Initial Public Offering Debt Financing Merger Investment Banking Advice Secondary Offering Acquisition of another business
State & Year of Inc.		No. of Shareholders
Audited Financials: YesNo  Reviewed: YesNo   Business plan available? YesNo
Industry		SIC code:
Assets:
Current Assets:
Fixed Assets:
Other Assets:
Total Assets:
Liabilities:
Current Liabilities:
Long Term Liabilities:
Total Liabilities
Stockholder Equity:
Total Liability & Stockholder Equity
Summary Income Statement (3 years) (Current, Last, Prior) Total Revenues: Net Income (Loss) Retained Earnings (Loss)
Business Summary: Management Team: President:  Yes No   Years Industry Experience: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 over 30 CFO: Yes No Years Industry Experience 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 over 30 Other: Number Total Years Experience Directors: Total   # Insiders # Independent Total number of employees
List amounts and types of debt or equity financings completed:
Describe current debt or equity offerings and/or needs:
Describe industry or growth plans:
Give 3 year summary growth estimates: Year One Year Two Year Three Revenues EBITDA Earnings Shareholder Equity
Describe any plans to go public:
Other comments:
Please supply business, banking, audit and personal references: