NVCA Membership

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Firm Name

Main Office Address

City

State

Zip

Phone

Fax

Internet Address

Primary Contact

E-mail

INVESTMENT PROFESSIONALS: List name, title and e-mail at main office

Name 1

Title 1

E-mail 1

Industry Preferences 1

Name 2

Title 2

E-mail 2

Industry Preferences 2

Name 3

Title 3

E-mail 3

Industry Preferences 3

Name 4

Title 4

E-mail 4

Industry Preferences 4

Name 5

Title 5

E-mail 5

Industry Preferences 5

Name 6

Title 6

E-mail 6

Industry Preferences 6

ADDITIONAL OFFICES

Address 2

City 2

State 2

Zip 2

Phone 2

Fax 2

Address 3

City 3

State 3

Zip 3

Phone 3

Fax 3

INVESTMENT PROFESSIONALS - Additional Offices

Name 7

Title 7

E-mail 7

Location 7

Name 8

Title 8

E-mail 8

Location 8

FIRM INFORMATION

Capital Under Management $

Year Founded

Type of Organization

Investment Size Preference

Revenue Preference

References Please identify two current NVCA members that are familiar with your firm’s investment activities (please include firm name and an investment professional we can contact)

Reference Firm 1

Contact Name 1

Reference Firm 2

Contact Name 2

Required You accept the responsibilities of membership, which includes payment of membership dues and the adherence of the professional standards set forth by the Association.

Your Name

Date

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