Name

Address

City

State

Zip

Phone

Fax

Email Address

*All email addresses provided will be added to the distribution list for the Indiana Venture Center eNews, a monthly electronic newsletter.

Do you fit the SEC definition of an accredited investor?

1. Any natural person whose individual net worth, or joint net worth with that person's spouse, exceeds $1,000,000; or
2. Any natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with that person's spouse in excess of $300,000 in each of those years and has a reasonable expectation of reaching the same income level in the current year.
3. 
   Yes No

What is your background/expertise in? (check as many as apply)

Computer Hardware Consumer Products Computer Software Distribution Education	Finance Internet Life Sciences Manufacturing Media	Medical/Health Care Retail Service Companies Telecom Transportation
Other

What particular investment categories interest you? (check as many as apply)

Computer Hardware Consumer Products Computer Software Distribution eCommerce	Financial Services Life Sciences Manufacturing Media Medical/Health Care	Retail Service Companies Telecom Transportation All
Other

What are your investment criteria (stage of development)?
(check as many as apply)

Growth/Preprofit Growth/Profitable MBOs

Mezzanine R & D Seed

Turnaround All

What type of investments do you prefer?
(check as many as apply)

Common Equity Convertible Debt Convertible Preferred Stock

Debt All None of the above

What is the typical size deal you are looking for?

$0-25,000 $25,001-50,000

$50,001-100,000 $100,000+

How many Angel investments have you made to date?

0   1 - 5   6 - 9   10 +

How many Angel investments might you make per year?

1   2   3   4   5

When you Angel Invest, do you want an active role in the company?

Yes - Board Seat Yes - Full Time Management Yes - Part Time Management Yes - Part Time Management

No

How would you prefer to “view” deals?

Monthly receptions at the Indiana Venture Center, Inc. One-on-one meetings with companies seeking capital Receptions within your region Review archived “Webinar” presentation at your leisure Webinar (live presentation via telephone and computer) All

In what physical proximity do you prefer to do deals?

Same City Within 1 Hour

Within 2 Hours Within Indiana

How would you prefer the Indiana Venture Center, Inc. communicate with you? Please indicate your preferences by prioritizing them (1 being the highest, 5 being the lowest).

1 2 3 4 5 Email 1 2 3 4 5 Mail 1 2 3 4 5 Through Assistant 1 2 3 4 5 Telephone 1 2 3 4 5 Fax
Assistant Name:
Assistant Telelphone #:
Assistant Email:

Please list any Angels and/or potential Angels that you suggest we confidentially add to AngelNet.

All email addresses provided above will be added to the distribution lists for the AngelNet News, an angel investor electronic newsletter, and the Indiana Venture Center eNews, a monthly electronic newsletter.