Registration Form

Company Name:* Address:* City:* State:* Zip*: Type of company*: LLC C corporation S Corporation other Contact Name:* Title:* Email address:* Office Phone:* Office Fax:* Mobile Phone:* Company Details and Status: Date Founded:* What do you do?*
(Maximum100 words) Explain anticipated use of Proceeds ($1,000.00):* Explain how these funds will impact your business efforts?* Competitive Advantages (What makes you special?) Maximum 100 words:* Management Team (As applicable) CEO/President/Executive Director:* CTO : VP Sales/ Development: Directors: Advisors: Company Description:* Product Offering
(or Science/Technology):* Analysis of your Marketplace
(100-150 words maximum) Description of Competition
(100-150 words maximum) Business/Revenue Model
(100 words): Submit Presentation:
Maximum 12 slide Power Point