Proving Grounds Application Form

Name

First Name

Last Name

Phone Number

Legal Company Name

Doing Business As (D/B/A) name:

Legal Form of Business

Do you have a business plan?

Website (if applicable)

List all owner(s) of the business or Major Shareholders, % owned and contact information for each:

Please list Management/Leadership - including Chairman/Woman of the Board, President, CEO, Key Management Members, Governing/Advisory Bodies:

County in which Business is Licensed:

Year product(s) or services(s) introduced?

Stage of business formation or immediate goals?:

Progess of current plans:

Past milestones & successes (if applicable)

Last year's Total Sales (if applicable):

Copy of Last year's Total Profit (if applicable):

Amount of Funds Sought:

Use of any funds sought:

Please describe your Product/Service:

Number and type of product lines:

Patents Held or Pending:

Licenses Held/Pending:

My needs and interest in this program are as follows:

Funding & Incubator Program(s) Access

Enclosed Office & Incubator Program(s) Access

Dedicated Work Space & Incubator Program(s) Access

Co-working Space & Incubator Program(s) Access

Incubator Program(s) Access with limited use of conference areas

Other

Expected Start Date:

Is there any other information you would like us to know?