Name:    Address: 

City:     State:  PA AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY  Zip:  County:

Country:    Phone:    E-mail:

Internet Address:   Fax number: 

Business Name:    Nature of Business: 

Principal Officer and Title: 

Brief Background of Principal Officers: 


Date Business was Established: 

New Business
Existing Business
Still In Planning Stages


Business Type?   Current Locations? 

Company Form:
C-Corp
S-Corp
LLC
other: 

Current Status of Business: 

Current Sales Revenue(monthly): 

Current Number of Employees:
full time employees:      part time employees: 

Type of Financing Employed to Date: 
Personal Resources: 
Private Investors:    
Venture Capital:      
Other:                   


Plans For Future Rounds of Financing: 

Status of Business Plan:
Business Plan Not Started
Business Plan In Preparation   Expected Completion Date: 
Business Plan Completed and Available For Review

Would You Like Help Writing A Business Plan:
Yes    No

How soon will you need the Incubator?  

Special Facilities Requirements:
Specify electrical, ventilation, floor load, etc.



Discuss The Resources That You Wish To Utilize:


Approximate Date You Desire To Locate In The Incubator:



Square Feet Needed For Business: 

For how long would you anticipate needing space? 6 mos. 9 mos. 12 mos. 12+ mos.

Business needs (list as many as necessary):
Conference Room  Administrative Support                    Phone                      Mailbox
             Computer        Business Mentoring                        Fax   Fast Track Training
        Work Station           Warehouse Space          Photocopier          Advisory Board
  Mailing Address                         Financing  Internet Access                         Intern
       Other Needs: