| PROFILE: |
 =
required field |
|
|
Email
|
|
| |
(e.g. mailid@domain.com)-
a valid address is required for the next stage of the application process |
|
Salutation
|
|
|
First Name
|
|
|
Last Name
|
|
|
State of residency
|
|
|
Age
|
|
|
Company (or self
employed)
|
|
|
Title/Position
|
|
|
|
Street address
|
|
|
Street address
|
|
|
City
|
|
|
State
|
|
|
Zip Code
|
- |
|
Phone Number
|
-- |
|
Fax Number
|
-- |
|
| ACTIVE COMPANY
INVOLVEMENT: |
| List all companies other than your
current employer that you are actively involved with. Also state what position you
hold with each one such as board member, controlling shareholder, or advisor. |
|
|
| HIGH TECH AND
STARTUP EXPERIENCE: |
| List your experience in startup and
high tech companies in the past and tell us what role you played. |
|
|
|
| PREFERED INVESTMENT
SIZE: |
| Tell us your preferred investment
size in a startup company? Check all that apply. |
| |
$25,000 to $49,000
$50,000 to $99,000
$100,000 to $249,000
$250,000 to $499,000
$500,000 and up |
| Check all industry segments where
you have significant experience: |
|
Software
Hardware
Information Systems
Electronic Commerce
Telecommunications
Networking and Internet
Semiconductors
Consumer products
Medical products
Other: |
| Give any additional information
you would like shown in your profile such as any role you would like to play in portfolio
companies, your interest in investing in future rounds, and other related experience. |
| |
|
|
| SEEDSTAGE NOTIFICATION: |
| How would you like to be notified
of new investment opportunities? |
| |
Email |
Fax |
| Notify me immediately of all
new investment opportunities as they are posted. |
| |
Yes |
No |
|
| If the answer is "No" above,
check all industry segments that you are interested in receiving investment opportunities
from. |
| |
Software
Hardware
Information Systems
Electronic Commerce
Telecommunications
Networking and Internet
Semiconductors
Consumer products
Medical products |
 |
|
|