Tell us about yourself
Name (required)	(President or CEO)
Company Name (required)
Company Address (required)
Company Address
City (required)
State (required)
Zipcode (required)
Phone Number (required)	(area code + number)
Fax Number	(area code + number)
E-mail Address (required)
Tell us about your company
How is your business organized?	--Select One Please-- Sole proprietorship Partnership LLC C Corporation S Corporation If other, please describe?
Date business started	(mo/day/yr)
Where started	city/state
Stage of development	--Select One Please-- Idea stage Early stage Prototype stage (manufactured & sold in small quantities) Developmental stage (product maturity, sales volume & mgmt.) Expansion stage (capable of standing on your own)
Number of employees	Full-time     Part-time
Do you have an existing written business plan?	Yes No
Is this a minority or woman-owned business?	Minority Woman-owned
Principals information	Principal 1 Name Title Phone % Owned Full/Part time --Select One Please-- Full-time Part-time Principal 2 Name Title Phone % Owned Full/Part time --Select One Please-- Full-time Part-time Principal 3 Name Title Phone % Owned Full/Part time --Select One Please-- Full-time Part-time
Type of business	--Select One Please-- High technology Service Retail Software Light manufacturing Other If other, please describe
Briefly describe your business
Briefly describe your background and experience
How is your product unique?
Describe target market and size
How can your product or technology be protected?	--Select One Please-- Patent Trademark Trade Secret Copyright Other If other, please describe
Primary source of financing	--Select One Please-- Savings Operating income Equity investment - private Equity investment - venture capital Debt - personal Debt - bank
How will you repay investors?
Current capitalization	--Select One Please-- $0 - $50,000 $50,000 - $100,000 $100,000 - $150,000 Over $150,000
Additional near-term contemplated capitalization
Total assets
Total revenue (past 12 months)
Annual growth rate (%)
Anticipated employment	Within one year: Full-time  Part-time  Indirect Within five years: Full-time  Part-time  Indirect
What do you consider your personal weakness?
Are you willing to accept and act upon advice from a Board of Advisors appointed for you?	Yes No
Incubator service requested	Resident (plan to move into the incubator) Affiliate (non-resident use of services only) If resident, what is the amount of office space needed? Sq. Ft.
Describe what you expect the incubator to provide
How long do you expect to be a BizTech client?	1 year 2 years 3 years
How did you hear about us?	--Select One Please-- Friend/Associate BizTech board member Advertisement Newspaper Newsletter Chamber of Commerce Search engine or referring site Other If other, please describe