Personal Information   First and Last Name:   Title:   Company Name:   Address:   City:   State/Province: Select State/Province Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Ontario Prince Edward Island Saskatchewan   Zip/Postal Code:   Country: Select Country United States Canada Other - Specify   Other:   Phone:   Ext:   Fax:   E-mail Address:   Web Site URL:     Business Information   Type of Business: Select Type of Business Healthcare Biotechnology IT Services High Tech Retail Service Consumer Products Industrial Products Entertainment Agriculture Hospitality   Number of Employees: Select Number of Employees Less than 10 10 to 20 20 to 50 50 to 100 100 to 250 250 to 500 500 to 1,000 Over 1,000   Yearly Sales Volume: Select Yearly Sales Volume 0 to $99,999 $100,000 to $249,999 $250,000 to $499,999 $500,000 to $1 M $1 M to $5 M $5 M to $10 M $10 M to $25 M Over $25 M   Number of Years in Business: Select Number of Years in Business Less than 2 2 to 5 5 to 10 More than 10     Financial Reorganization Information   Type Of Business: Select Type of Business Incorporated Unincorporated Self Employed   Do you have outstanding lawsuits or judgements currently filed against you, either personally or under the business name ? Yes No Does the company have outstanding lawsuits or judgements currently filed against it? Yes No Is a secure creditor threatening to seize assets? Yes No   Are any of the company's leases in jeopardy due to non-payment? Yes No Would the Company operate profitably and generate positive cash flow if it had no debt? Yes No Is the company in arrears on remittances of withholdings from payroll, provincial sales tax or GST, and are you personally exposed to these liabilities as an officer or director? Yes No Are you facing personal financial pressure due to other significant personal debts, including Revenue Canada? Yes No Comments:   I would like to subscribe to the businessmatchmaker.com E-newsletter:   © 2006 businessmatch-maker.com Inc. | businessmatchmaker.com™ is a trademark of businessmatch-maker.com Inc. Privacy Policy