How did you hear
about us?
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Internet Search LAUNCHfn.com website
Link from another web site Other (Input Name of
referral source)
Name of source
referring you. (website, person, etc.)
Salutation
Please select one Mr.
Mrs. Dr.
Ms.
First Name
Last Name
Email
Job Title
Company
If you are not the
president or CEO of the company, then who is?
Street Address
Suite or Bldg #
City
State
Zip Code
Country
Phone no.
Cell phone
Alternate phone no.
Fax no.
Website
What industry is the
company in?
Please select one Bio-Medical
Services Consumer Products Real
Estate
Distribution/Transportation
Entertainment/Media
Franchise/Retail Homeland Security
Government
Mining/Minerals/Petroleum
Manufacturing
Technology Software
Telecom/Wireless
Internet Other
What is your legal
structure?
Please select one
Not Incorporated LLC
S Corp C Corp
What is the stage of
the company?
Please select one
Seed stage (Proof of concept)
Start up stage (Ready
to Launch) Early stage (Sales under $500,000
Expansion stage (Sales $500,000 to $3,000,000)
Late stage (Sales > $3,000,000)
Buy-out or Acquisition
IPO stage (Sales > $25,000,000)
How many years has
the company been in business?
Describe the business
in 200 words or less.
Who is the company's
target or demographic market?
What are the
company's current revenues?
Is the company cash
flow positive?
Is the company
profitable?
What was last year's
revenue?
What is your investor
relations budget?
What is the forecast
for next year's revenue?
How much capital is
the company seeking?
What type of capital
is the company seeking?
Please select one or more
Unsure Purchase Order / Contract Financing
Working Capital Loan / SBA
Active Investor "Exec with Check" Private Investor (Angel)
Venture Capital PIPE - Micro IPO
What types of
services is the company seeking?
Please select one or more
Investor events Investor relations campaign
Business plan services
Loan facilitation
Strategic planning
Capital funding strategy
Investor document preparation Other
How much have the
founders invested in the company?
What is the total
amount invested in the company?
Does the company have
a PPM?
Please select one Yes
No Partially complete
Have investor term sheet
Does the company have
a business plan?
Please select one Yes
No Partially complete
Does the company have
a investor presentation?
Please select one Yes
No Partially complete
How long did it take
you to complete this form?
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