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Pipeline application

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									PARTICIPANT PROFILE Instructions
Fill in each row. To better answer your needs we ask that you fill out the form in ENGLISH.
CONTACT INFORMATION / OVERVIEW
Company Name:                                             Company Phone:
Address:                                                  Website:
Contact Name:                                             Title:
Contact Phone:                                            Contact Mobile:
Contact Email:                                            Date Submitted:



THE BUSINESS
Elevator Pitch (describe
why one would be
interested in investing in
your company in 6
sentences):

Product(s):

Current Product Status:

Underlying Technology or
Intellectual Property:

Legal (patents):



BUSINESS STRUCTURE / SERVICE PROVIDERS
Business Type (public or
private):

Date of Incorporation:

Country of Incorporation:

Legal Counsel:

Accountants:




To participate in this program, contact Leonard Gold: lgold@burnslev.com / 617.345.3831 or
Charles Godbout: charles.godbout@ca.pwc.com / 514.205.5020.
THE MARKET
Describe Your Target
Markets:

Size of Your Market(s):

Competition (list your 3 top
competitors and your
position against each):



SALES
Current Sales and
Customers:

Outlook for Future Orders:

Distribution:

Number of Employees:



MANAGEMENT AND STAFFING

Summary Bios:

Advisors, Directors, etc.:



REVENUE & PROJECTIONS (IN THOUSANDS US$)
                               2006      2007        2008        2009        2010        2011

Revenues:

Operating Expenses:

EBITDA:




To participate in this program, contact Leonard Gold: lgold@burnslev.com / 617.345.3831 or
Charles Godbout: charles.godbout@ca.pwc.com / 514.205.5020.
CAPITAL
                            1. Investor:                       Amount (in US$):
                            2. Investor:                       Amount (in US$):
                            3. Investor:                       Amount (in US$):
                            4. Investor:                       Amount (in US$):
Amount Raised to Date:
                            5. Investor:                       Amount (in US$):
                            6. Investor:                       Amount (in US$):
                            7. Investor:                       Amount (in US$):
                            8. Investor:                       Amount (in US$):
Identify Your Current
Stockholders:

Investment Seeking (US$):

Proposed Use of New
Financing:

Additional Comments:




To participate in this program, contact Leonard Gold: lgold@burnslev.com / 617.345.3831 or
Charles Godbout: charles.godbout@ca.pwc.com / 514.205.5020.

								
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