01

Background Information

Full Legal Name of Business

Mailing Address

Contact Name

(person authorized to sign for the company)

Business Phone

(xxx-xxx-xxxx)

Email

Date of Business Formation

State of Incorporation

02

About the Company

Describe your company's mission

Do you have any patents or trade secrets?

How is your company disrupting the status quo?

Do you have a prototype? How many more months of development does it need?

What is your total addressable market (TAM) and your projected piece of it?

What is your go-to-market strategy and who are your competitors? How are you better than your competition?

Briefly describe your team’s capabilities to execute on your mission.

How much funding have you received to date? How much are you aiming to raise in the next 12 months? What is your monthly run rate?

What are 3-5 things you want to achieve by being part of the incubator.

This could include access to faculty for advice or project work, access to student interns or graduates, capital introductions, etc.

Are you interested in space? If so, what would your space requirements be for the next one to two year?

03

Confirm Information

I hereby certify that, to the best of my knowledge, the preceding information is true and complete. I further certify that I will report, in writing, to the Technology Incubation Program (TIP) any changes to the information contained herein.

Name

Title

Electronic Signature

Date