2013 HCap Growth Call for Presenters

Thank you for submitting your application for the 2013 HCap Growth program.

Please note the following:

* There is no application fee.

* Presentations: Each company accepted will have 20 minutes to present their company. All presentations will take place on Wednesday, December 4, 2013.

* Presenters: 1 individual per company may present.

*General Information(Required.)

Presenting Executive & Title: *

Company: *

Year of Start up: *

Address:

City:

State:

Zip:

Mobile Phone:

Office Phone:

email:

Please list your leadership team (regardless of who will be presenting):

CEO/President:

COO:

CFO:

CMO:

*Please indicate your 2012 company revenues:(Required.)

*What market sector(s) do you operate In?(Required.)

*Is your company a:(Required.)

Healthcare Provider (providing healthcare services to patients)

Ancillary Product/Service Provider (products and services for healthcare providers)

*Please describe your company's unique position in your sector (if applicable): (Required.)

*Who owns the majority interest in your organization?(Required.)

Other

Outside Investors

Angel Investors

Private Equity

Healthcare

Other (please specify)

*Please provide a very brief history about the growth of your company (e.g., when it started, when or whether profitable, initial strategy, growth trajectory, major obstacles, and outside investors along the way, etc.)(Required.)

*What is your top-line growth rate for the past five years?(Required.)

*What is your planned top-line growth rate for the next five years?(Required.)

*Is your expected growth:(Required.)

Mainly Organic

Mainly M&A

Even Split Between Organic and M&A

*Please indicate if you are interested in telling your story to:(Required.)

Financial (private equity and investment banks)

Healthcare/strategic

Both

*Do you have competitors?(Required.)

Yes

*If "Yes", please list them:(Required.)

Thank you again for your submission. We will review your application and contact you regarding your status.

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