Akron BioInvestments Funds Application

About You

*Title:

*First Name:

*Last Name:

*Company Name:

*Job Title:

*Country:

*Address:

*City:

*Zip/Postal Code:

*Phone Number:

Cell Phone Number:

*Email:

Website:

How did you hear about us?

Please Specify:

I was asked to fill out this form by a person at

About Your Business Idea

*Industry Categorization:

*Provide a brief summary of your company/product/idea. Please indicate what is unique:

(100 words or less)

*How much cash has been invested in the business to-date?

Please indicate sources of investment(s) (check all that apply) Owner/FounderAngels
Friends and FamilySales Revenue
Venture CapitalNone
LoansOther
Grants

*How much cash are you seeking at this time?

Are you interested in pursuing a high-growth business strategy which may involve raising money from outside sources, including venture capital and other funds? YesNoNot Sure

Are you aware that taking outside capital will result in decreased equity? YesNoN/A

Is your company minority-owned or managed? YesNo

If yes, please specify Minority Group

Is your company woman-owned or managed? YesNo

*Including yourself, how many full-time employees work for the company?

Do you currently have a presence in the United States? YesNo

If yes, where?

If yes, what type?

Are you planning to establish a presence in the US? YesNo

If yes, what kind? Sales agents, distributorsManufacturing
Market developmentResearch and development

*The funding is only available to businesses located in the City of Akron. By selecting yes, you confirm you are either currently located in the City of Akron or will agree to relocate here as needed. YesNo

Information regarding your company will need to be disclosed to Akron BioInvestments as part of the loan/grant process. If any of this information is deemed by your company to be confidential or proprietary in nature, that should be disclosed to Akron BioInvestments prior to the delivery of any such information.