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.

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* General Information

Presenting Executive & Title: *

Company: *

Year of Start up: *

Address:

City:

State:

Zip:

Mobile Phone:

Office Phone:

email:

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

CEO/President:

COO:

CFO:

CMO:

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* Please indicate your 2012 company revenues:

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

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* Is your company a:

Healthcare Provider (providing healthcare services to patients)

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

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

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* Who owns the majority interest in your organization?

Other

Outside Investors

Angel Investors

Private Equity

Healthcare

Other (please specify)

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* 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.)

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* What is your top-line growth rate for the past five years?

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

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* Is your expected growth:

Mainly Organic

Mainly M&A

Even Split Between Organic and M&A

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* Please indicate if you are interested in telling your story to:

Financial (private equity and investment banks)

Healthcare/strategic

Both

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* Do you have competitors?

Yes

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* If "Yes", please list them:

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