NVCA Membership

Firm Name *

Main Office Address *

City *

State *

Zip *

Phone *

Fax

Internet Address

Primary Contact *

E-mail *

INVESTMENT PROFESSIONALS: List name, title and e-mail at main office

Name 1

Title 1

E-mail 1

Name 2

Title 2

E-mail 2

Name 3

Title 3

E-mail 3

Name 4

Title 4

E-mail 4

Name 5

Title 5

E-mail 5

Name 6

Title 6

E-mail 6

ADDITIONAL OFFICES

Address 2

City 2

State 2

Zip 2

Phone 2

Fax 2

Address 3

City 3

State 3

Zip 3

Phone 3

Fax 3

INVESTMENT PROFESSIONALS - Additional Offices

Name 7

Title 7

E-mail 7

Location 7

Name 8

Title 8

E-mail 8

Location 8

FIRM INFORMATION

Capital Under Management $ *

Year Founded

Type of Organization

Total Invested Over Last 12 Months: $

Investment Size Preference

Stage of Development
SeedEarlyExpansion LaterAcquisition/BuyoutMezzanine All

Revenue Preference

Geographic Preferences
National (U.S.)InternationalNew England New York Metro AreaMid-AtlanticSoutheast SouthwestMidwestNorthern California Southern CaliforniaPacific Northwest

Industry Preferences
BiotechnologyCleanTechCommunications Computer HardwareComputer ServicesComputer Software Consumer-RelatedElectronicsEnergy/Environmental Financial/Business ServicesHealthcare ServicesIndustrial Products Internet/E-CommerceMedical DevicesMultimedia/Entertainment

References Please identify two current NVCA members that are familiar with your firm’s investment activities (please include firm name and an investment professional we can contact)

Reference Firm 1

Contact Name 1

Reference Firm 2

Contact Name 2

Required You accept the responsibilities of membership, which includes payment of membership dues and the adherence of the professional standards set forth by the Association.

Your Name *

Date *

or Reset

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