BROKER PROFILE

 HEALTH CAPITAL INVESTORS, INC.

545 Fifth Avenue - 9th Floor - New York, NY  10017

Telephone:  212-421-4040 - Facsimile:  212-421-7171
Name:
Title:
Company Name:
Address:
City:
State:
Zip Code:
Phone:
Fax:
Year Established:
Web Site:
Email:

**Please submit a brief professional history with this form (if available)

**Please provide 2 professional references (Name, Phone, Relationship)
Types of medical providers on which you plan to focus your marketing efforts? (check all that apply)

__Physicians

__Nursing Homes

__Home Health Companies

__Durable Medical Equip.

__All

__Other:______________________________

__Rehab / Physical Therapy Centers

__Diagnostic Facilities

__Hospitals

__Chiropractors

__Group Medical Practices   
Do you have any particular connections to those providers specified? 
     If yes, please explain:
Targeted Market Segment:

__Retail ($5,000 - $100,000 in outstanding accounts receivable)  

__Middle Market ($100,000 - $1,000,000)  

__Institutional ($1,000,000 +)  

General Business Region:  

__Northeast 

__Northwest

__Southeast  

__Southwest

__Midwest  

__National  

__International  

__Other:  _____________________
Number of medical transactions previously brokered:
Do you have any formal brokering education?

     If yes, please specify:
Do you have any previous experience in the health care industry?

     If yes, please explain:
Do you have any previous experience in the finance industry?

     If yes, please explain:
Will you be dedicating your business exclusively to the health care market?
Special services offered to your clients:
Other businesses in which you are involved: