Penn Venture（一）.docVIP

Please complete the following template and Submit to: gpeck@, dmkline@ or Fax to 717.236.2315 Date, Place Type of Incorporation Capital Raised Sources of Funds Cash on Hand Financial Need Number of Employees Employer Identification No. SIC Code [Company name] [Address] [City, State, Zip] [Phone] [Fax] [Email] [Contact person] [please try to keep responses to the space provided] [global/domestic sales for most recent year] [what is the annual growth rate in the industry?] (in $000s) 2002 2001 2000 Gross Revenue Sales Growth COGS Gross Profit Operating Expense EBIT Additional financial data for prior fiscal year only (in $000s) Total Assets Shareholder Equity Net after-Tax Profit (Loss) Retained Earnings (Deficit) Tax data for prior fiscal year (in $000s) Federal State Local Income Employee payroll withholdings [Please provide a brief narrative description of your company’s history including significant milestones. To the extent that they are available, please provide financial data at right.] (in $000s) Year 1 Year 2 Year 3 Year 4 Year 5 Sales Sales Growth COGS Gross Profit Operating Expense EBIT [including but not limited to legal, accounting, and technical advisors] [if Penn Ventures invests in your company, how will we exit our investment? Owner buyback? Merger/acquisition? Sale to third party? Initial public offering?] Sources Amount (in $000s) Uses Working capital or inventory purchase Plant modernization or leasehold improvement Acquisition of all of part of an existing business Consolidation of obligations New building or plant construction Acquisition of machinery or equipment Land acquisition or dwelling construction Marketing activities Research development Other (please specify) [ Note: Penn Venture Partners will be more interested in financing some of these categories than others. [Please provide a br