Business Name

Street Address

City State Zip

BUSINESS PROFILE::
a. Nature of product or service

b. How is product protected (e.g., copyright, patent, other)?

c. Current Form of Business (check the one that applies)
Corporation State
Partnership
Sole proprietorship
State of Incorporation

d. Current Status of Business
(e.g., conceptual, working on prototype, etc).

e. Number of Employees
Full time Part time
Currently
Projected within 12 months

f. How long has your company been in business?

g. Company's strategy for success:

h. Summary assessment of the market & what
the company will bring to it:

i. Brief description of the management team:

Financial Information::

a. Provide 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 six months in the incubator. (Please use Excel or other comparable spreadsheet program.)

b. Current gross sales:

c. What are your current sources of funding?
Personal
Family/Friends
Commercial bank loans
Research grants
Government loans
Seed money
Stock
Venture Capital
Other (describe):

d. Do you require additional funding?
Yes No

If yes, what are your funding requirements over the next year?

When will the funding be necessary?

What is the intended use of the funding?
Operating capital
Equipment
Debt Retirement
Other

Incubator Support::

a. How much office space do you require?
Immediate In six months

b. Are you requesting technology support (web/application/database server and storage)?
Yes No

If yes, describe your additional requirements in detail.

d. How long do you anticipate being in the program?

e. Check the areas for which your company needs support:
Business plan refinement
Technical support for product
Administrative support (payroll, accounting, etc)
Legal support (incorporation, patent, etc)
Finance/funding (locating sources of funding)
Other
Additional comments regarding support being requested:

Other Items

a. Have you read and do you satisfy the criteria for admission?
Yes No

b. Do you understand that an equity interest may need to be provided to the Louisiana Technology Park as compensation for the services being provided?
Yes No