GENESIS HUB INTAKE

GENESIS HUB INTAKE FORM

Hey!

Thanks for your interest in Genesis. The information collected here will help us determine how we move forward with the creation of our new Genesis space, who may be interested and how we can best service the needs of of diverse and talented innovative community. We want to know as much as possible about you so we can offer an amazing place and space to residence of the Genesis hub and program.

Please take 10 minutes to complete this intake form. We will follow up with you directly for next steps.

Kind regards,

The Genesis Team

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* 1. Name of your organization or business:

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* 2. Main contact person's name:

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* 3. Main contact person's email:

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* 4. Current Mailing address:

Name:

Address line:

City:

Postal Code:

Country :

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* 5. Website:

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* 6. Have you applied to be a resident of the Genesis incubator programs in the past?

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* 7. My organization's legal structure is as a:

Not for profit charity with legal status

Not for profit charity- status pending

Not for profit charity-Jewish in nature

Not for profit charity

Social Enterprise

Entrepreneurial venture

For-profit business

A start up

A corporations

I am just curious about what Genesis has to offer- I have no organization.

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* 8. Your organizations' mission:

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* 9. How long has your project/business been operating?

Under 1 year

1-3 years

3-5 Years

6-7 years

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* 10. Which of the following five words best describes your organizational stage?

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* 11. Describe your target audience:

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* 12. What is the need for this work? *

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* 13. Briefly describe your product, programs or services *

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* 14. Briefly describe your organization's impact to date and or measures of success *

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* 15. Do you currently have a board or a leadership group? If yes, please list the names and titles of all members:

Name and role:

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* 16. Are you currently employed outside of your project/organization? *

Yes

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* 17. If yes, how many hours per week do you work outside of this project? Explain if you expect this to change in the next two years. *

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* 18. Why do you want to participate in the Genesis: UJA Federation's Centre for Jewish Innovation?

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* 19. How many days per week will you require or desire a desk at the Genesis: UJA Federation's Centre for Jewish Innovation Hub? Also, how many staff will need a desk?