| Name of
Owner/Principal |
|
SS# |
|
|
| DOB |
|
Place of Birth |
|
|
| If not US,
specify citizenship: |
|
Address: |
|
| Apt # |
|
City, |
|
|
|
| ZIP |
|
Phone
(Home) |
|
Work
|
| Email
Address |
|
Marital
Status |
|
# of dependents
|
|
|
|
|
|
Company Information |
| Name |
|
DBA |
|
|
| Tax
ID# |
|
Sales
Tax# |
|
|
Business
Licenses:
(type n/a if none) |
|
Business
Existence |
|
|
|
| Current
Location |
|
Work
Stoppages? |
|
|
| Physical
Address |
|
Mailing (if
different) |
|
|
|
| Phone |
|
Fax |
|
|
| Legal
Structure |
|
Profit
Structure |
|
|
|
Ownership |
| Name of Principal |
|
Position |
|
|
| Name of Principal |
|
Position |
|
| Name of Principal |
|
Position |
|
| % Owned |
|
Active in operation
(FT or PT) |
|
| % Owned |
|
Active in operation
(FT or PT) |
|
|
| % Owned |
|
Active in operation
(FT or PT) |
|
|
| Employees on
payroll |
Full-time
|
Are any
employees physically impaired? |
|
| Part-time |
| Year-round |
| Seasonal |
| Do you
anticipate hiring additional employees? |
f yes,
When?
How many?
Skills Needed? |
Training
programs desired for current or new employees |
|
|
|
|
|
|
Company Product/Service |
| What does the company produce
or market? |
|
%
of Sales? |
|
|
| Do
you have competitors in Bay County and if so, how is your product or
service unique? |
|
Would
you consider a teaming arrangement or joint venture with them?
Why? |
|
|
|
|
|
|
Marketing Strategy |
| Type of
Customer |
|
Customer Market
Base |
|
| Customer
Demographics (age, sex, location, buying habits, etc.) |
|
Marketing/Advertising
Plan (Check all that apply) |
|
|
|
|
|
|
|
Financial Status |
|
Banking Reference
Banking Reference |
|
Have
any of the principals declared bankruptcy? If yes, when and
under what circumstances. |
|
|
|
Account #
Account # |
|
Start-up companies must answer the following and complete a cash flow
analysis. |
Does the company have funding available to finance its operation? |
|
|
How much money is required? |
|
|
|
|
|
Operational Information |
| Will your
company require special power, lighting, ventilation,
materials handling, storage, water access? |
|
Will
your company require specific interior security measures
(vault, keyless door locks, etc.)? |
|
| Will
your company require secured parking or exterior storage
facilities? |
|
Does
your company have specific waste or chemical disposal
requirements? |
|
| In
what areas of small business management would you need or like
assistance? |
|
Why
do you want to locate/relocate your business in the Incubator? |
|
| How
long do you expect to stay? |
|
|
|
|
|
|
|
|
|
Education |
| |
Name |
Location |
Major |
Degree/Cert. |
| High School |
|
|
|
|
| College/Tech |
|
|
|
|
| College/Tech |
|
|
|
|
|
|
|
|
|
Military
Service |
| |
Branch of service/rank |
|
Dates of service |
|
|
|
|
|
|
Business Ownership
Experience |
| Company Name |
State |
% Owned |
Product/Service |
Dates of Operation |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Work Experience (2 most recent positions) |
| 1.
Date of Employment |
|
Reason
for Leaving |
|
|
|
Company |
|
Product/Service |
|
|
City |
|
|
Phone |
|
| 2.
Date of Employment |
|
Reason
for Leaving |
|
|
|
Company |
|
Product/Service |
|
|
City |
|
|
Phone |
|
|
|
|
|
|
Explain briefly why you think your company
will succeed. |
|
|
|
|
|
|
|
| To validate your entries, what year is it? |
|
|
|
|