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
Name	Title	E-mail
Name	Title	E-mail

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 $		Year Founded

TYPE OF ORGANIZATION Partnership Corporation Venture Capital Division of a Corporation SBIC LLC LP TOTAL INVESTED OVER THE LAST 12 MONTHS: $ INVESTMENT SIZE PREFERENCE: <= $500,000 <= $1M <= $5M <= $20M >= $20M All STAGE OF DEVELOPMENT Seed Early Expansion Later Acquisition/Buyout Mezzanine All	REVENUE PREFERENCE None <= $1M <= $10M <= $100M >= $100M All 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 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) Firm name Contact Firm name Contact *You accept the responsibilities of membership, which includes payment of membership dues and the adherence of the professional standards set forth by the Association. Print name Date