Request for Additional Information If you are considering going public through a reverse merger with a clean public shell, please take time to fill out our simple form and we will contact you to discuss ways we can help you achieve your goals of taking your private company public. Your Full Name: 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 Common shares issued & outstanding: 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.) Top of Page
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:
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.)
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