General Information Company Name Address City, State and Zip Applicant s Name Applicant s Job Title Phone Number Email Address Type of Organization (LLC, C- Corp, etc.) Years/months in Business Name Ownership Structure (List Principals/Owners owing more than 10% of the company.) Title Percentage of Ownership Are you applying to the Technology Validation stage (up to $25,000) of the Pre-Seed Investment Program? Yes No Are you applying to the Business Model Validation stage (up to $50,000 requiring a company match) of the Pre-Seed Investment Program? Yes No Are you applying to both the Technology and the Business Model Validation stages (up to $75,000 requiring a $50,000 company match) of the Pre-Seed Investment Program? Yes No Page 1 of 6
Which technology field does your business concept fall under? Please mark. IT and Software: Green Energy: Advanced Materials: Energy and Electronic Products: Other: Advanced Manufacturing: Health Tech: Major Milestones: (Please list the major milestones the company wants to accomplish using the Launch Place s Pre-Seed investment.) Category Description Full Disclosure (Please carefully review and answer correctly.) Yes No Have you read the criteria of the Pre-Seed Investment Program listed on the Launch Place s website (www.thelaunchplace.org)? Are you willing to abide by the criteria of the Pre-Seed Investment Program listed on the Launch Place s website (www.thelaunchplace.org)? Should the Company/Applicant answer yes to any of the following questions, they must provide any and all details under separate cover and submit it with this application. The Business must provide all pertinent information including names, dates, times, types, dollar amounts, circumstances, status and dispositions relevant to the appropriate question(s): Yes No Is the business a franchise or license company? Does the business have any other affiliates, subsidiaries, or parents? Are there any tax liabilities outstanding from previous reporting periods? Does the business have any contingent liability? Is the business applicant presently a party to any claim or lawsuit? Has the business or any proposed guarantor ever declared bankruptcy? Is the business an endorser, guarantor or co-maker for obligations not listed on the financial statements? Does the business hold any patents or pending patents? Page 2 of 6
Business Description (Please provide a detailed description of your business in this section.) Product or Service (Provide a description of the product or service being offered, including an explanation of the unique features of your product or service that is addressing a pain in the market.) Business Model (Describe how the company will generate revenues.) Target Market (Describe the market that you propose to serve with your business, including the size of the market. Who will buy your product or service? Where are they located? Page 3 of 6
Marketing and Distribution Strategy (Please provide your marketing strategy, how will you attract, keep, and reach these customers? Competition (Please provide a competitive landscape of your product or service industry.) Team (Share name(s) and experience of owners/management team.) Page 4 of 6
Company Financials (Please provide detailed current and projected financial status of the company.) Current Sources of Capital (List all sources of capital over $5,000 including grants, competition winnings, loans, investors, or other creditors.) Sources Type $ Amount Financial Projection: (Please provide three-year financial projections, including revenues and expenses, cash flow statement, and current balance sheet additional attachments may be required.) Use of Funds: (Please provide the detailed use of the Launch Place s Pre-Seed Investment funds.) Category Description $ Amount Page 5 of 6
Authorization The information contained herein is true, complete and accurate to the best of my knowledge. I understand that this information will be used by the Launch Place to review my application. I agree to provide additional information as requested by the Launch Place. I have read the investment criteria for the Launch Place Pre- Seed Investment Program and agree to accept them. By: Title: Date: Page 6 of 6