Company Name: Company URL (if applicable): First Name: Last Name: Address Street 1: Address Street 2: City: Zip Code: (5 digits)State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Daytime Phone: Evening Phone: Email: Business Tagline: A short and attractive tagline to describe your proposition: Provide a short description of the investment opportunity you are presenting in the form of elevator pitch or vision/mission statement: Describe your target buyer's need or desire. Avoid technical terms and only focus on explaining the opportunity. Include the profile of target customers: Describe how you want to address the need or opportunity. Concentrate on essential value proposition and customer benefits: Explain your business model and expected profit. Provide supporting data such as market size, market share and growth rate: Describe your current & future competitors. Demonstrate knowledge of the landscape and your competitive advantage: Introduce your team and emphasize on what YOU bring to the table. Explain the role and responsibility of each member and any other human resources that you would need to execute the plan.: General Industry: --Please Select-- Biotechnology & Drugs Business Products and Services Computers and Peripherals Consumer Products and Services Electronics/Instrumentation Financial Services Healthcare Services Industrial/Energy IT Services Media and Entertainment Medical Device & Equipment Networking and Equipment Real Estate & Construction Retailing/Distribution Semiconductors Software Telecommunications Transportation Other Specific Industry/Segment: Development stage: --Please Select-- Concept/Idea Startup Prototype Product Launched Revenue Stage Break Even Profitable High Growth Year founded: Nr. of 'full-time equivalent' employees 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 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 Legal structure: --Please Select-- Not formed yet Sole Proprietorship partnership Corporation Amount sought?: --Please Select-- Less than $50,000 $50,000 - $100K $100K - 250K $250K - $500K $500K - $1 Million $1M - $2 Million $2 - $5 Million $5 - $10 Million $10 - $20 Million $20 - $50 Million $50 + Million Current monthly burn rate: $ Current monthly revenue: $ Total amount raised to date: $ Total debt to date: $ Referred by (if applicable):