Early Stage East - Venture Capital Showcase for the East Coast




Application Attendance is limited and available on a first-come, first-served basis. Last year's event sold out, so register early! Companies MUST apply online. For credit card orders only. Complete and submit the form below. Confirmation will be provided via e-mail. If not paying by credit card, be sure to send a check, as no applications will be processed until further payment is received. Mail payments to: Early Stage East Three Mill Road Suite 201A Wilmington, DE 19806 For assistance in completing this application, it may be helpful for you to reference our sample application. For a link to this sample, click here.

Early Stage East 2008 Application
Resume Saved Application
Referred by
Referring Organization	Other:
Company
Address 1
Address 2
City
State
Zip
Contact First Name		MI
Contact Last Name
Phone	( ) -
Fax	( ) -
Email
Website URL:
Credit Card:	This is a secure page.
Credit Card #:	Application Fee: $500.00 (Do not enter dashes or spaces)
CVC:
Expiration date:	/
Cardholder's name:	If you are accepted your credit card will be charged $500.00

Management Team & Titles

At least two members of the management team must be identified. For each member, you must complete
at least one Employment History, with all fields included. There is a 250 character maximum for all job descriptions.

Team Member 1

Name:

Title:

Employment History

Start Date / End Date

Company:

Title:

Job Description
250 characters

Employment History

Start Date / End Date

Company:

Title:

Job Description
250 characters

Employment History

Start Date / End Date

Company:

Title:

Job Description
250 characters

Team Member 2

Name:

Title

Employment History

Start Date / End Date

Company:

Title:

Job Description
250 characters

Employment History

Start Date / End Date

Company:

Title:

Job Description
250 characters

Employment History

Start Date / End Date

Company:

Title:

Job Description
250 characters

Team Member 3

Name:

Title:

Employment History

Start Date / End Date

Company:

Title:

Job Description
250 characters

Employment History

Start Date / End Date

Company

Title

Job Description
250 characters

Employment History

Start Date / End Date

Company

Title

Job Description
250 characters

Team Member 4

Name

Title

Employment History

Start Date / End Date

Company

Title

Job Description
250 characters

Employment History

Start Date / End Date

Company

Title

Job Description
250 characters

Employment History

Start Date / End Date

Company

Title

Job Description
250 characters

Company History

Year Founded
Number of Employees
Cash Funding to Date	$
Bank
Auditor
Law Firm
Industry
Other
Amount of funding sought	$
Current Investors

Funding

Source 1 250 character max
Amount of Funding	$
Use of Funds 250 character max
Date of Funding

Source 2 250 character max
Amount of Funding	$
Use of Funds 250 character max
Date of Funding

Source 3 250 character max
Amount of Funding	$
Use of Funds 250 character max
Date of Funding

Company Profile

Business Description 250 character max
Company Description 250 character max
Product Line or Service 250 character max
Technology/Proprietary Rights 250 character max
Market Opportunities 250 character max
Marketing/Sales and Distribution 250 character max
Manufacturing 250 character max
Competition 250 character max

Financial Information (actual and projected)

Please note that negative figures should be denoted with a "-", and cutting and pasting data may cause problems submitting the application.

	2007	2008	2009	2010	2011
Revenue	$	$	$	$	$
*EBITDA	$	$	$	$	$
Pre-tax Income	$	$	$	$	$
Net Income	$	$	$	$	$