Title ---Mr.Ms.Dr.Other
Full Name*
Company Name*
Job Title*
Address* ---United StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNagorno-KarabakhNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandTurkish Republic of Northern CyprusNorthern MarianaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTransnistria PridnestrovieTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsIsle of ManUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther
Phone Number*
Cell Phone Number
Email Address*
Website
How did you hear about us?
I was asked to fill out this form be a person at: ---Akron Community Service Center and Urban LeagueAkron Global Business AcceleratorAkron Minority Business Development OrganizationAkron SCOREBad Girl VenturesBioEnterpriseBlackstone LaunchPadBraintree Center for Business InnovationGlengary, LLCGLIDE (Great Lakes Innovation and Development Enterprise)Innovation Fund at Lorain County Community CollegeJumpStart Higher Education Collaboration CouncilJumpStart Inclusion AdvisorsJumpStart VenturesPTAC-Kent Regional Business Alliance-Kent State UniversityMAGNET (The Manufacturing Advocacy and Growth Network)MTSBDC at Kent State UniversityNEO PTAC-Lake County Port AuthorityNEOTEC ITAC Kent state UniversityNorTechNorth Coast Angel FundNorth Coast Opportunities Technology Fund of Cuyahoga CountyOhio Aerospace InstituteOhio ITACOhio SBDC at Kent Regional Business AllianceOhio SBDC at Kent State University Stark CampusOhio SBDC at Kent State University Tuscarawas CampusOhio SBDC at Lake County Port AuthorityOhio SBDC at Lorain County Chamber of CommerceOhio SBDC at Summit Medina Business AllianceOhio SBDC at Youngstown State UniversityOhio SBDC/MBDC at the Urban League of Greater ClevelandSWCO PTAC at ColumbusUrban League of Greater Cleveland-Entrepreneurship CenterUrban League of Greater Cleveland-MBACWooster Opportunities FundYoungstown Business IncubatorNobodyTeacher/ProfessorOther*
If you choose other for the last question, please specify here
Industry Categorization* ---Advanced MaterialsAerospace & DefenseAgricultureAutomotive & TransportBankingBioSciencesBusiness Products & ServicesChemicalsConstructionConsumer Products & ServicesEducationElectronicsEnergy/Power/PropulsionEnvironmental Services & Equip.Financial ServicesFood & BeveragesHealthcareIndustrial ManufacturingInformation Technology/InternetInsuranceLeisureMedia & EntertainmentMedicalMetals & MiningPharmaceuticalsReal EstateRetailSecurity Products & ServicesTelecommunicationsTransport ServicesOther
Provide a brief summary of your company/product/idea. Please indicate what is unique: (100 words or less)*
How much cash has been invested in the business to-date?*
Please indicate sources of investment(s): (check all that apply)
Owner / FounderVenture CapitalGrantsSales RevenueFriends and FamilyLoansAngelsNoneOther
If you checked "other" in the last question, please specify here:
Are you interested in pursuing a high-growth business strategy which may involve raising money from outside sources, including venture capital and other funds?*
YesNoNot Sure
Are you aware that taking outside capital will result in decreased equity?*
YesNoN/A
Is your company minority-owned or managed?*
YesNo
If yes, please specify Minority Group
---African AmericanNative AmericanLatin-American / HispanicAsian-Indian, Asian-Pacific, Pacific Islander American
Is your company women-owned or managed?
Including yourself, how many full-time employees work for the company?*