Address:

City, State, Zip Code:

Country, if not USA:

Company Name:

State of Incorporation:

Type of company:

Your position:

Daytime Phone (including area code):

Fax number (including area code):

E-Mail Address:

Web Site URL:

Do you have a business plan?

YES

NO

Preferred shares issued & outstanding:

Number of Shareholders currently (approximately):

Approximate annual sales:

Approximate annual net earnings:

Approximate total Assets:

Approximate total net worth:

Date of last audited financials:

Why do you want to go public?
(Enter as much information as you wish.)