Presenting Company Registration
Capital Conference
7a.m. to 2p.m.

PRESENTING COMPANY:
Company Name: 
(Exactly as you would like your name to appear on your profile-this also must match the way you are listed with the SEC.)
Address: (Exactly as you would like your name to appear on your profile-this also must match the way you are listed with the SEC.)
Address:
City: State: Zip:
Country: Website:  email:
Toll Free #: Other:   Fax:
Public Exchange: Symbol: Private Company: Looking for Financing:
Sector:    Industry:
SCIA  MEMBER SPONSOR:
 Firm: Rep.:
PRESENTING COMPANY FEES:( Due upon application to reserve your presentation date)  
AMEX VISA MC Discover Bank Debit Card ATM
Cardholder: Credit Card Billing Zip Code:

Card Pin #
Card # Exp/ 3 Digits on Back of Card (even on AMEX)

Credit Card Billing Street Address #: Electronic Signature:

 Company Check Overnight    Check #   

Corporate and Overnight Checks to: SCIA is Preferred - 33671Chula Vista Ave,Dana Point, Ca, 92629
BASIC FEE: $3600.00; Early Limited Time Fee May Apply
Returning Company fee with same Management : $3300.00

Charge me $300.00 to be part of the cocktail reception hour at the luncheon. SCIA will promote you immediately and exclusively

Main management name to be announced listed first:
1. Presenters Name: Title:
Main Management Cell:Email:
2. Name: Title:

ADDITIONAL COMPANY MANAGEMENT: Please add $30.00 each:

 3. Name: Title:
 4. Name: Title:

TOTAL FEES DUE UPON APPLICATION TO RESERVE TIME SLOT:$ (Add additional fees over 2)

Presenting Company Profile

COMPANY OBJECTIVE: 
Stock Exposure: Public Offering (type and stage):
Private Placement: PIPE: (Private Investment in  a Public Entity, stock offered with registration rights)
Other
List the date on the Offering/PPM/PIPE: Bridge Loan: Other:

OFFERING/FINANCING SIZE AND STRUCTURE: (Please answer TBA, where applicable)
Offering Amount $No. of Units Available@ $per unit
Type of Stock & Reg./Rule with No. of Warrants Available
@ $  Additional Structure Detailed Information: 

MARKET SUPPORT INFORMATION (Please Indicate "Proposed Stock Symbol, Offer Price and Exchange" for IPO):

NYSENasdaq : NMSAMEXNasdaq : Small Cap OTC : BBNQB : Pink
Other Exchange:
Stock Symbol: Recent Bid: (Proposed Offer Price, If IPO)$
52Week Range:Shares Out:Market Cap:
Est. Float Ave 3 m. Vol.: 1yr. Target Est:

1. ENCAPSULATE COMPANY OVERVIEW (Products, markets, uniqueness, objectives, and competition);
2. INVESTMENT ATTRACTION / NEW DEVELOPMENTS / PROJECTION STATEMENTS / Why should an investor buy your stock or offering?
(Points on How Investing in Your Company May be Timely):
200 Word Max


SELECTIVE FINANCIAL HIGHLIGHTS actual     forecasted

Month of Your Yr. End:

Fiscal Years Ending:	Months ending:
Revenue:
Pre-Tax Income:
Net Income:
Earnings/Share:
Weighted Ave. Shares:

PRESENTATION AIDS YOU WILL PROVIDE:
Overnight CD PowerPoint or DVD   *emailed PowerPoint

At least 3 days prior to conference

FINAL COPY ONLY Labeled with Co. Name to: RayKau@sciaconference.com


(Our wireless remote mouse pointed at the screen will let you control your presentation.)
My Company would like to provide as a gift(s) to give away to draw more attention at the podium to my presentation.

We are interested hostingor joint hostinga reception.

Name of person filling out this form:
Title: Phone: Ext.: Email:

Cancellation Policy: If received in writing 20 days in advance, SCIA will refund 75% of the total fees.  The presenting company shall be liable for 100% of the total fees during the 20 day period.

Management reserves the right to refuse companies.

We look forward to having you join us. Call when we may be of service.