Please, also review our Due Diligence Checklist.

GENERAL INFORMATION

Company Name____________________________________________

Address__________________________________Suite____________

City______________________State__________Zipcode___________

Telephone (___ )___________________Fax (___)_________________

URL_____________________________________________________

DESIRED TRANSACTION (circle one and indicate amount of capital required where appropriate)

Private Placement
Venture Capital
Direct Public Offering
Initial Public Offering
Merger
Acquisition of another business

Other:__________________________________________

PRINCIPALS TO CONTACT

1. Name______________________________Title__________________

Home Address______________________________________________

City________________________State__________Zipcode__________

Home Telephone (___ )_______________________________________

2. Name____________________________Title____________________

Home Address______________________________________________

City________________________State__________Zipcode__________

Home Telephone (___ )_______________________________________

ORIGINATOR'S NAME (if different from yourself)

Name_____________________________Title____________________

Home Address_____________________________________________

City_______________________State_________Zipcode___________

Home Telephone (___ )______________________________________

Referred by: YES__NO__

If yes, do they expect a finder's fee? YES__NO__

Name_________________________Phone (___ )________________

BUSINESS BACKGROUND

Corporate History____________________________________________

 _________________________________________________________

__________________________________________________________

Founded In__________Founded By_____________________________

Changes in management and/ or ownership_______________________

__________________________________________________________

CURRENT BUSINESS (include descriptive literature or brochures)

Makes, distributes, or source of sales or revenue____________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

Patents or licenses___________________________________________

__________________________________________________________

Sales and Marketing Techniques________________________________

__________________________________________________________

__________________________________________________________

Company has (number)

_________Total Employees

_________Salespeople

_________Other (describe):____________________________________

Company sells in the following areas______________________________

__________________________________________________________

Company sells to_____________________________________________

__________________________________________________________

CORPORATE DATA

Incorporated under laws of state of___________________Date________

MANAGEMENT AND CAPITALIZATION

Common shares authorized_________________Outstanding__________

Preferred shares authorized_________________Outstanding__________

Other______________________________________________________

TITLE

(Check if director)

Chairman

Name______________________________Salary________Shares Owned______Age______

Remarks___________________________________________________________________

President

Name______________________________Salary________Shares Owned______Age______

Remarks___________________________________________________________________

Executive Vice President

Name_____________________________Salary_________Shares Owned______Age______

Remarks___________________________________________________________________

Vice President

Name_____________________________Salary_________Shares Owned______Age______

Remarks___________________________________________________________________

Secretary

Name_____________________________Salary_________Shares Owned______Age______

Remarks___________________________________________________________________

Treasurer

Name_____________________________Salary_________Shares Owned______Age______

Remarks___________________________________________________________________

Management

Name_____________________________Salary_________Shares Owned______Age______

Remarks____________________________________________________________________

Name_____________________________Salary_________Shares Owned______Age______

Remarks___________________________________________________________________

Other Members of the Board of Directors:

__________________________________________________________________________

MAJOR COMPETITION

(If any competitors are public, indicate so and attach a S&P or Value Line sheet, if available)

1. Name of Company_______________________________________________________

Public_____________________________________City_________________State______

Approximate dollar volume if known____________________________________________

2. Name of Company_______________________________________________________

Public_____________________________________City_________________State______

Approximate dollar volume if known____________________________________________


Comments regarding competition______________________________________________

_______________________________________________________________________

MAJOR SUPPLIERS

1. Company_______________________________________________________________

Contact person________________________________________Title_________________

Address__________________________________________________________________

City___________________________________State_________Zipcode_______________

Telephone (__ )___________________________Fax (__ )__________________________

2. Company_______________________________________________________________

Contact person________________________________________Title_________________

Address__________________________________________________________________

City___________________________________State_________Zipcode_______________

Telephone (__ )___________________________Fax (__ )__________________________

3. Company_______________________________________________________________

Contact person_________________________________________Title________________

Address__________________________________________________________________

City____________________________________State_________Zipcode______________

Telephone (__ )___________________________Fax (__ )__________________________

FINANCIAL INFORMATION

Primary Bank

_________________________________________________________________________

Address__________________________________________________________________

City____________________________________State_________Zipcode______________

Telephone (__ )___________________________Fax (__ )__________________________

Bank Officer/ Contact person handling account___________________________________

Secondary Bank

_________________________________________________________________________

Address__________________________________________________________________

City__________________________________State__________Zipcode_______________

Telephone (__ )___________________________Fax (__ )__________________________

Bank Officer/ Contact person handling account___________________________________

Law Firm

_________________________________________________________________________

Address__________________________________________________________________

City____________________________________State___________Zipcode____________

Telephone (__ )___________________________Fax (__ )__________________________

Partner familiar with company_________________________________________________

Accounting Firm

_________________________________________________________________________

Address__________________________________________________________________

City____________________________________State___________Zipcode____________

Telephone (__ )___________________________Fax (__ )__________________________

Partner/ Accountant familiar with company_______________________________________

SUMMARY OF EARNINGS

For fiscal year ending____________________________

From fractional period ending______________________

Or estimated earnings for_________________________

			19__	19__	19__	19__

Net Sales			_____	_____	_____	_____

Net Revenues		_____	_____	_____	_____

Cost of Sales			_____	_____	_____	_____

Gross Profit			_____	_____	_____	_____

Percent of GP		_____	_____	_____	_____

Pretax Profit			_____	_____	_____	_____

TAX*			_____	_____	_____	_____

Net Profit (after Tax)		_____	_____	_____	_____

Percentage (NAI) 		_____	_____	_____	_____

**If no tax provided, please explain why______________________________________

_____________________________________________________________________

PLEASE INDICATE STATUS OF THE FOLLOWING FINANCIAL REPORTS
FURNISHED BY THE COMPANY OR AUDITORS

P&L Statement

Dated:_________Audited:______YES____NO
Audited____Mailed____None_____

Remarks:________________________________________________________________

Balance Sheet

Dated:_________Audited:______YES____NO
Audited____Mailed____None_____

Remarks:________________________________________________________________

Annual Reports

Dated:_________Audited:______YES____NO
Audited____Mailed____None_____

Remarks:________________________________________________________________ 
Interim Reports

Dated:_________Audited:______YES____NO
Audited____Mailed____None_____

Remarks:________________________________________________________________

Prospectus

Dated:_________Audited:______YES____NO
Audited____Mailed____None_____

Remarks:________________________________________________________________

Dunn & Bradstreet

Dated:___________	

Remarks:________________________________________________________________

S & P Report (if public)

Dated:___________

Remarks:________________________________________________________________

Company Literature

Remarks:________________________________________________________________

BALANCE SHEET (Please attach)

Please, also review our Due Diligence Checklist.