Innovation Intake Questionnaire: Survey

1.

Tell us about yourself.

Your Name

Company Name

Company Address 1

Company Address 2

City/Town

State/Province

Zip/Postal Code

Country

Email Address

Phone Number:

2.

What is, or will be, the URL for your website?

3.In which industry do you work?

4.

Product or Service Description:

5.Business Description: Please provide a clear, complete, and succinct explanation of your company.(Required.)

6.

Business Model: Please describe how your company makes money, including distribution channels.

(Required.)

7.

Ask & Offer: How much new capital do you need to get your venture to positive cash flow and to profitability?

(Required.)

8.

Ask & Offer: Are you seeking equity or debt financing?

Equity

Debt

Combination of Equity and Debt

Not sure

9.Ask & Offer: What are you offering the investor for the equity or debt provided? Percentage of company? Interest rate?(Required.)

10.

Ask & Offer: How will the investor get their money out? Exit strategy?

(Required.)