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Basic Information
Company Name:
Contact Name:
E-Mail Address:
Confirm E-Mail Address:
Contact Phone:
Book Reference
Are You Here In Reference To The Book Giveaway?
Yes:    No:
Company Address
Street
City
State
Zip Code
General Information
Cell Phone:
Is The Business Incorporated ? Yes    No
Annual Sales Volume:
Under $500,000
$500,000 to 1 Million
1 Million to 5 Million
Over 5 Million
Type Of Business:
Preference For Providing Your Information
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Phone Interview: Online:

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Financial Information
Please Provide The Following Financial Information
Accounts Receivable:
Inventory:
Machinery & Equipment:
( Market Value )
Company Owned Real Estate:
( Market Value )
Total Mortgage Against Real Estate:
Secured Party Debt:
( Bank or Lender )
Taxes:
(Behind or Liened )
Accounts Payable
Creditor Suits or Judgments:
Major Areas of Interest or Concern:
( Click All That Apply )		 Financing
Taxes
Judgments And Liens
Bankruptcy Alternatives
Creditor Issues
Establish Credit
Improve Or Create Cash Flow
Increase Sales
Sell My Business For The Most Money Possible
Survival
Other

Additional Concerns Or Explanations