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| 2 |
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| 3 |
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Position |
Phone and Fax |
E-mail |
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| 4 |
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| a. |
Nature of product or service: |
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| b. |
How is product protected
(e.g., copyright, patent, other)? |
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| c. |
Current Form of Business (check
the one that applies) |
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i. Corporation
State:
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ii. Partnership |
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iii. Sole proprietorship |
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iv. State of Incorporation |
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| d. |
Current Status
of Business (e.g., conceptual, working on prototype,etc). |
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Full time |
Part time |
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Projected within 12 months |
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| f. |
How long has your company been
in business? |
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| g. |
Company's strategy for success: |
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| h. |
Summary assessment of the market
& what the company will bring to it: |
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| i. |
Brief description of the management
team: |
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| 5 |
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| a. |
Summary of historical
and forecasted financial data including revenue and net income
(include five-year projection). The company must identify
its source of working capital for at least the first 6 months
in the incubator. |
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| c. |
What are your current sources
of funding? |
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i. Personal |
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ii. Family/Friends |
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iii. Commercial bank loans |
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iv. Research grants |
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v. Government loans |
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vi. Seed money |
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vii. Stock |
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viii. Venture capital |
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ix. Other
(describe): |
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| d. |
Do you require additional
funding? |
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No |
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If yes, what are your funding
requirements over the next year? |
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When will the funding be
necessary? |
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What is the intended use
of the funding? |
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i. Operating capital |
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ii. Equipment |
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iii. Debt Retirement |
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iv. Other |
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| 6 |
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| a. |
How much office space do
you require? |
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sq ft |
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sq ft |
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| b. |
Are you requesting technology
support (web/application/database
server and storage)? |
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No |
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If yes, describe your technology
requirements including operating systems, database management
system, and storage requirements. |
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Does your company require
any additional technology support (specialized equipment,
data center space, etc.)? |
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No |
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If yes, describe your additional
requirements in detail. |
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| d. |
How long do you anticipate being
in the program? |
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| e. |
Does your company seek support
in the following areas: |
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Technical support for product |
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Administrative support
(payroll, accounting, etc) |
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Legal support (incorporation,
patent, etc) |
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Finance/funding (locating
sources of funding) |
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Additional comments regarding
support being requested: |
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| 7 |
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| * Indicates required fields |
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