EXIT i2n Company Eligibility Survey Question Title * 1. Contact Information Name Title Email Phone OK Question Title * 2. Please provide the following company information: Company Address City/Town State/Province ZIP/Postal Code Phone Number OK Question Title * 3. Company President/CEO OK Question Title * 4. Company President/CEO email OK Question Title * 5. What is the formation date of your company? OK Question Title * 6. Is your company registered to do business in PA? No Yes OK Question Title * 7. Date moved to current location: OK Question Title * 8. Company Website: OK Question Title * 9. Please provide a short description of your company which can be included on the i2n website (2-3 sentences): OK Question Title * 10. Please provide a short description of the intellectual property or innovative technology being developed by your company: OK Question Title * 11. Is your company an industry or university spin-off? No Yes If yes, from which company or university did your company spin-off? OK Question Title * 12. Organization FEIN: OK Question Title * 13. NAICS Code OK Question Title * 14. Is your company woman, minority, or veteran owned? Check all that apply. Woman Minority Veteran OK Question Title * 15. Please estimate your company annual revenue. OK Question Title * 16. If you are still in a pre-revenue research/product development stage, when do you anticipate drawing revenue? OK Question Title * 17. What is the current total full-time employee count at your company? OK Question Title * 18. What is the total annual cost of full time employee payroll for your company? OK Question Title * 19. Please indicate the amount of Research, Development, Testing and Evaluation (RDT&E) expenditures made by your organization. OK Question Title * 20. Do you have access to the start-up investments and funding that you need? Yes No OK Question Title * 21. What are your preferred funding sources? Sales Public Grants Private Grants Angel or Venture Capital Debt Financing(Loans) Other (please specify) OK Question Title * 22. What is the minimum threshold amount for funding you need within the next six months? OK Question Title * 23. Will your company be hiring any full-time positions within the next six months? Yes, 1-3 Yes, 4-10 Yes, 10+ No If yes, please specify what position(s) and number of openings. OK Question Title * 24. Will any of your employees be attending technical trainings within the next six months? Yes, 1-3 Yes, 4-10 Yes, 10+ No If yes, please specify what trainings. OK Question Title * 25. What resources does your company need to grow?(Check all that apply) Banking Legal Accounting Human Resources Insurance Real Estate Technology Tax Credit Strategic Advisor University Connection Other (please specify) OK DONE
