Name:
Title:
Company Name:
Address 1:
Address 2:
City:
State:	-- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip Code:
Phone:
Fax:
Email:
Subject Company:	If different than the Company Name listed above.
Type of Entity:	-- Partnership LLC C Corporation S Corporation
Business Interest Under Consideration:
Description of Business:
Latest Annual Revenues:	$  (Enter figures without commas.)
Latest Annual Assets:	$  (Enter figures without commas.)
Purpose of Valuation:	For example, estate planning, tax, gifting, mergers and acquisitions or fairness opinion.
Valuation Date:	Month  -- January February March April May June July August September October November December  Day  -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  Year  -- 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 For example, date of death, gifting date or transaction date
Time Frame for Completion:	-- less than one week 1 to 2 weeks 2 to 4 weeks 4 to 8 weeks other
Questions or Comments: