Basic Information

Legal Company Name *

DBA / Trading Name (if different)

Business Entity Type * Select... Sole Proprietorship Partnership LLC S-Corp C-Corp Non-Profit Cooperative

Primary Industry * Select... Technology Healthcare Finance Retail Manufacturing Services Real Estate Food & Beverage Education Entertainment Construction Transportation Other

Industry Specialization / Niche

Employer Identification Number (EIN)

Date of Formation/Incorporation

Fiscal Year End Select... December 31 January 31 February 28 March 31 April 30 May 31 June 30 July 31 August 31 September 30 October 31 November 30

Contact Details

Principal Business Address *

City *

State * Select... AL AK AZ AR CA CO CT DE 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

ZIP Code *

Mailing address is different from business address

Mailing Address

Business Phone Number *

Fax Number (if applicable)

Primary Business Email *

Company Website

Key Personnel

CEO / President Name

CEO Email

CFO / Financial Officer Name

CFO Email

COO / Operations Manager Name

Legal Counsel / Attorney Name

Law Firm Name

Registered Agent Name

Registered Agent Address

Business Details

Company Mission Statement

Company Vision Statement

Core Business Values

Primary Products/Services Offered *

Target Market / Customer Demographics

Unique Value Proposition / Competitive Advantage

Number of Employees Select... 1 (sole owner) 2-5 6-10 11-25 26-50 51-100 101-250 251-500 500+

Projected/Current Annual Revenue Select... Under $100K $100K-$500K $500K-$1M $1M-$5M $5M-$10M $10M-$50M $50M+

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