Shiawassee Region Business Incubator Owosso, Michigan
All information submitted is considered confidential Company Information
Company Name: ______________________________________________________________________ Company Address: _____________________________________________________________________ Contact: _________________________________ Title: ______________________________________ Company Phone: __________________________ Contact Phone: ______________________________ E-mail: __________________________________ Website: ___________________________________
When and where was the company incorporated?
Date of incorporation: _____________________ State of incorporation: _______
What is the legal status of the company? (Circle one)
LLC LLP C- Corporation S- Corporation General Partnership Sole Proprietorship
Contact information for major shareholder(s)/principal partner(s)
Name: ____________________________________ Title: _____________________________________ Address: _____________________________________________________________________________ City: _____________________________________ State: ______ Zip Code: _____________________ Primary Phone: _____________________________ Secondary Phone: ___________________________ Email: ___________________________________________________ Ownership %: ______
Address: _____________________________________________________________________________ City: _____________________________________ State: ______ Zip Code: _____________________ Primary Phone: _____________________________ Secondary Phone: ___________________________ Email: ___________________________________________________ Ownership %: ______
Name: ____________________________________ Title: _____________________________________ Address: _____________________________________________________________________________ City: _____________________________________ State: ______ Zip Code: _____________________ Primary Phone: _____________________________ Secondary Phone: ___________________________ Email: ___________________________________________________ Ownership %: ______
Contact information for other employees
Name: ____________________________________ Title: _____________________________________ Address: _____________________________________________________________________________ City: _____________________________________ State: ______ Zip Code: _____________________ Primary Phone: _____________________________ Secondary Phone: ___________________________ Email: ___________________________________________________ Full/Part Time: _____________
Name: ____________________________________ Title: _____________________________________ Address: _____________________________________________________________________________ City: _____________________________________ State: ______ Zip Code: _____________________ Primary Phone: _____________________________ Secondary Phone: ___________________________ Email: ___________________________________________________ Full/Part Time: _____________
Appendix B – Sample Client Application Form
City: _____________________________________ State: ______ Zip Code: _____________________ Primary Phone: _____________________________ Secondary Phone: ___________________________ Email: ___________________________________________________ Full/Part Time: _____________
Future Employee Estimates
One year from now: Full-time Employees: _____________ Part-time Employees: ____________ Two years from now: Full-time Employees: _____________ Part-time Employees: ____________
Does your company have a business plan? (Circle one) Yes No
Briefly describe your business: what products/services it offers, what demand it fulfills, what its target market is, etc.
Do you hold licenses/patents for any products/services you are developing?
Circle all that apply: Yes No In progress
Please itemize and quantify your operating costs for the first six months.
Describe how your business will be funded for the next six months.
What is/was the initial capitalization of your business? (Circle one)
$0-$50,000 $50,000-$100,000 $100,000-$250,000 >$250,000 Have you secured any of the following to capitalize your business? If so, for how much?
Government grant/contract: $____________ From which agency? ____________________________ Angel investments: $____________ Venture capital investments: $______________
Corporate partner Investment: $___________ Self-funded: $_____________
Other: $__________ Source(s): ________________________________________________________
Does your company require space in an incubator facility? (Circle one) Yes No If so, how much space will your company need? _________ square feet
What type of space will be needed? ________________________________________________________ Will your company require any special facility accommodations? If so, please specify:
Please describe assistance that may be requested from the incubator:
Accounting: __________________________________________________________________________ Financial: ____________________________________________________________________________ Production: ___________________________________________________________________________ Legal: _______________________________________________________________________________ Marketing: ___________________________________________________________________________ Technical: ____________________________________________________________________________ Management: _________________________________________________________________________ Other: _______________________________________________________________________________
Do you currently have any of the following services?
Attorney’s name: _____________________________ Firm: __________________________________ Accountant’s name: ___________________________ Firm: __________________________________
Appendix B – Sample Client Application Form
Bank name: __________________________________ Location: _______________________________ Which of the following do you have at the bank? (Circle all that apply)
Savings Account Checking Account Line of Credit Credit Card
Would you be interested in utilizing co-op students or interns? Yes No
If so, in what capacity? _________________________________________________________________
My signature below indicates that I have completed the above form truthfully and accurately.
I authorize the Shiawassee Region Business Incubator to verify information contained in this form by contacting bank, trade, or other sources as it deems appropriate.
I understand that this application, when submitted, becomes property of the Shiawassee Regional Incubator Initiative and will be retained whether or not the application is approved.
Signature: _______________________________ Date: _____________________________________ Name: __________________________________ Title: _____________________________________ To submit this application:
1. Save the form on your own computer first
2. Attach the application to an e-mail to (Incubator director): [email protected] (sample) 3. Or mail the completed application to
Incubator Manager
Shiawassee Region Business Incubator 12345 Address Drive
Business Incubator Owosso, Michigan
All information submitted is considered confidential
Survey of Entrepreneurs for Mixed-Use Business Incubator Program
Business incubation programs are designed to help entrepreneurs' grow their businesses from the start-up phase to full sustainability. Typically, a business will graduate from an incubator program within three years. These programs will sometimes operate within a facility (see below), but do not necessarily have to. A program that operates without a facility may be referred to as a 'virtual incubator' or 'virtual business incubation program.' To promote entrepreneurial success, a business incubation program will offer entrepreneurs a multitude of services by connecting them with local accountants, business consultants, lawyers, and other professionals, as well as community partners, industry partners, and each other. To complement these services, business incubation programs also offer entrepreneurs training, one-on-one consulting, seminars, mini-courses, and workshops, many of which will be sponsored and facilitated by local professionals. Business incubation facilities are buildings that are constructed or reconfigured to accommodate the needs of an entrepreneurial community. The incubation facility can offer office space, specialized production space, and equipment. The rent for the facility and production space is often reduced, since it is offset by the sharing of space and equipment. Generally, an incubator manager will provide onsite assistance and facilitation of services to businesses housed in the facility. The primary goal of incubation is to create new jobs and to foster an entrepreneurial culture. The survey you are about to take will be used to gauge the entrepreneurial interest in your area in order to determine whether an incubator program or facility is appropriate for your community. Your participation is completely voluntary, and you may skip any question you do not feel comfortable answering. You also may withdraw at any time. Your contact information will be fully protected. Thank you for choosing to participate in this survey in the interest of your community. It will take approximately 15 minutes to complete.
Please provide your personal contact information: Title (Mr. / Mrs. / Ms.): ______
Name: ____________________________________
Street Address: _________________________________________________ Street Address (Line 2): __________________________________________ City: _______________________
State: ______________________ Zip Code: ___________________
Phone Number: _________________________
Email Address: __________________________________________ Year of Birth (yyyy): _________
1). Is your business currently in operation? Yes