Page 1

Incubation Program Application Please save and e-mail completed forms to with the subject "BizTech Application". All fields marked with '*' are required.

Entity Name* Federal Tax ID#* Business Phone Number* Business Address* Web Address E-Mail Address Type of Business Structure*

Sole Proprietor Partnership C - Corporation S - Corporation Limited Liability Partnership Limited Liability Company

Date Established* How did you hear about BizTech?*

Business Ownership*

100% Female 100% Male >51% Female >51% Male

Last Quarters Sales* Last Months Payroll Cost* Full Time Employees (Includes Owners)* Part Time Employees* Total Employee Count*

Commercial Bank Phone Number

Legal Representation Phone Number

Accountant Phone Number

Insurance Provider Phone Number

For each owner please fill out the following. Please leave unneeded sections blank.

Full Name* Address* Phone Number* Social Security Number* Title* Percent Ownership*

Full Name Address Phone Number Social Security Number Title Percent Ownership

Full Name Address Phone Number Social Security Number Title Percent Ownership

Please describe your product and or service*

If you have supplementary materials such as product specifications, photos, or marketing materials please attach them in addition to this file when sending it in.

Do the owners or entity as a whole currently hold any patents?*





If yes, please describe

Will your entity require any special electrical arrangements?* If yes, please describe

The following questions are intended to provide a summary of your business. Note that each field has a 1000 character limit and help text is available by clicking the question marks on the right. What do you do?*

How do you do it and what makes you unique?*

How do you make money?*

Who are your customers and partners?*

Describe your market(s) and how large it is (are they)?*

What are the competing solutions?*

When do you expect to be successful?*

Who makes up your organization and what does it look like?*

The information in this Biztech application is provided for the purpose of applying for tenancy under the Biztech Business Incubation Program. The information is accurate to the best of the applicant’s knowledge. The applicant understands that personal and/or business information may be requested pursuant to this application and hereby grants consent for such information to be provided to Biztech. By signing this application, the applicant(s) understand that they are giving Biztech permission to obtain a consumer credit report that will be reviewed and evaluated pertaining to this application. The applicant understands that Biztech retains sole decision whether this application is approved, disapproved, or modified. Completion and submission of the application by the applicant to Biztech is merely a request for entrance and shall not be construed as an approval nor a commitment by Biztech to rent space to applicant. The applicant agrees to hold harmless Biztech, its staff, employees, agents, volunteers, officers, and trustees from any and all claims, injury, cause of action whatsoever, whether previously, now or hereafter incurred, from any acts or omissions by Biztech, its staff, employees, agents, volunteers, officers, and trustees pursuant to any technical assistance provided. The applicant agrees that Biztech assumes no responsibility for the success or failure of the applicant’s existing or proposed business venture. The role of Biztech is consultative in nature and any advice or information offered may or may not be used per the applicant’s discretion. Therefore, the applicant releases Biztech and its staff, employees, agents, volunteers, officers, and trustees from any liability associated with the applicant’s existing or proposed business venture.

By entering the following you certify that all participating parties have read and agreed to the acknowledgment above. Entity Name* Full Name of Owner 1* Title*

Full Name of Owner 2 Title

Full Name of Owner 3 Title

biztech application  

Incubation Program Application