If you are human, leave this field blank.
Business Name
*
Business Email Address
*
Business Phone Number
*
Company Website / URL
Business Structure
*
Subchapter C Corporation
Subchapter S Corporation
Limited Liability Company
Partnership
Other
Are you willing to participate in quarterly business reviews?
*
Yes
No
Are you willing to submit quarterly reports?
*
Yes
No
Are you willing to receive guidance from business professionals?
*
Yes
No
Are you willing to receive guidance from business professionals?
*
Yes
No
Do you have a completed business plan?
*
Yes
No
Please provide a history of this business? (eg. Start Date, Accomplishments, Collaborations or any other relevent information
Please identify what activities will be performed in the Praxis Center for Venture Development?
Please provide detailed information regarding grants or other funding received to date?
Please indicate any additional funding requirements for the next 36 months of operation?
Do you have liability insurance coverage greater or equal to $1,000,000.00
*
Yes
No
Please provide details of any business liability insurace coverage including Provider Name, Coverage Amount, Expiration Date and Policy Number
Name of Company Officer #1
Email
Phone
LinkedIn
Name of Company Officer #2
Email
Phone
LinkedIn
Name of Company Officer #3
Email
Phone
LinkedIn
Number of Present Employees?
*
Number of Employees Projected in One Year?
*
Number of Employees Projected in Two Years?
*
Number of Employees Projected in Three Years?
*
Do you require Laboratory space?
*
Yes
No
Desired Space Availability Date?
Square Feet of Office Space Required in Year 1?
List any specialized office equipment or machinery that requires special facilities:
Will you be using any flammable, volatile, or toxic chemicals on site at any time? Please list, and describe in detail the methods, procedures and requirements involved:
Credit Reference Name 1
Phone
Email
Credit Reference Name 2
Phone
Email
Credit Reference Name 3
Phone
Email
Submit
