Type of Company:

Industry

Year Company Founded

Lifecycle

Average No. Employees

F/T:

P/T:

Number of Equity Owners:

General Mgr:

Approx 3 Yr Annual Revenue

Last 12 Mos:

Prev 12 Mos:

3 years ago:

Growth Potential next 3 to 5 Years:

New Investment Req’d:

Exit Time Frame:

Exit Strategy ( check all that apply ):

Exit Preparation

Valuation

Growth Proforma

Due Diligence Binder

Advisors

CPA:

Attorney:

Exit Planner:

Other:

Contact Name

Best Time To Call

Time Zone

Phone

E-mail Address

Additional Questions/ Comments

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