Application For Membership

Firm Name
Main Office Address
City State Zip
Telephone Fax  
Internet address
Primary Contact E-mail

Investment Professionals
Please list name, title ,and e-mail address at main office location
Name Title E-mail
Name Title E-mail
Name Title E-mail
Name Title E-mail
If your firm has multiple offices, please attach a separate sheet that lists all contact information for each location and a list of investment professionals and their email address. Please indicate which professionals are at which location. Maximum number of investment professionals is ten (10).

Additional Offices
Address
City State Zip
Telephone Fax  

Address
City State Zip
Telephone Fax  

Investment Professionals
Please list name, title, e-mail address, and office location
Name Title
E-mail Location

Name Title
E-mail Location

Name Title
E-mail Location

Firm Information
Capital Under Management $
(If investing from a dedicated pool of capital)		 Year Founded

TYPE OF ORGANIZATION

TOTAL INVESTED OVER THE LAST 12 MONTHS: $

INVESTMENT SIZE PREFERENCE:


STAGE OF DEVELOPMENT
Seed
Early
Expansion
Later
Acquisition/Buyout
Mezzanine
All

REVENUE PREFERENCE

None
<= $1M
<= $10M
<= $100M
>= $100M
All

GEOGRAPHIC PREFERENCES
National (U.S.)
International
New England
New York Metro Area
Mid-Atlantic
Southeast
Southwest
Midwest
Northern California
Southern California
Pacific Northwest

INDUSTRY PREFERENCES
 Biotechnology
 CleanTech
 Communications
 Computer Hardware
 Computer Services
 Computer Software
 Consumer-Related
 Electronics
 Energy/Environmental
 Financial/Business Services
 Health Care Services
 Industrial Products
 Internet/E-Commerce
 Medical Devices
 Multi-Media/Entertainment

REFERENCES:
Please provide the names of two NVCA members who are familiar with your firm’s activities (member list can be found on NVCA website www.nvca.org/members.html).

Firm name
Name of
Individual
Firm name
Name of
Individual


I accept the responsibilities of membership, which include the payment of membership dues and the adherence to the professional standards set forth by the Association.

Print name
Date