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Founder's name *
Name of Business
Website
Phone *
Fax
Email *
Address
Partner(s)/Principal(s) Name 1 *
Partner(s)/Principal(s) Name 2
Partner(s)/Principal(s) Name 3
Phone *
Phone
Phone
% ownership *
% ownership
% ownership
Attorney Name
Phone
Accountant Name
Phone
Bank Name
Phone

BUSINESS INFORMATION

New Business
Existing Business
Year Established *
Where was the business started? *
Number of Full-Time Employees
Number of Part-Time Employees
Legal Structure of Business
Sole Proprietorship
Partnership
Corporation (C, S, or LLC)
Please Describe the Business*
Ideal Stage
Early Stage
Prototype Stage (manufactured & sold in small quantities)
Developmental Stage (product maturity, sales volume & management capability)
Expansion Stage (capable of standing on your own)
Briefly describe your business, product, service, and associated technology *
Please list the type of services/assistance your company will require: *
How did you hear about us?
Additional comments:

I verify that this information is current, accurate, and that it may be confirmed.

Signature *
Date