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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

SPACE REQUIREMENTS

Square Footage you are interested in
Desired Date of Occupancy

ELECTRICITY REQUIREMENTS

Volts
Amps
Special Lighting Needs?
Other Special Needs?

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 *

Estimated Employment (Direct/Indirect)

At Time of Occupancy

Full Time
Part Time
Indirect

One Year Later

Full Time
Part Time
Indirect

Within 3-5 Years

Full Time
Part Time
Indirect
Please list the type of services/assistance your company will require: *

FINANCIAL INFORMATION

What are (will be) the primary sources of financing for your business?

Current capitalization requirements of your business?

$0-$50,000
$50,000-$100,000
$100,000-$150,000
Over $150,000
Are you willing to accept and act upon advice from a board of mentors appointed for you?
Are you willing to have your financials and business plan reviewed by the board quarterly?
How did you hear about us?
Additional comments:

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

Signature *
Date