Pre-Application

Developing the Roots of Small Business

2109 West Market Street Johnson City, TN 37604

Pre-Application

Title:

First Name:

Last Name:

Company Name:

Address:

Contact Numbers

Home:

Work:

Email:

How many full-time employees does your business have?

Business Address: (if different from above)

Business Activity:

How did you hear about the Innovation Laboratory?

Does your business currently have any relationship with ETSU faculty or programs?
Yes No
If so, please explain:

What assistance are you looking for?

Please describe briefly your innovation - What is it? What will it do?:

What stage is it at? Concept/Prototype/Well Developed, etc.

Have you filed a patent?
Yes No

What is the priority date?

What are your future plans for the innovation?
License the Idea
To Start a New Business
Other
If Other please specify

Do you have a business plan? Yes No

Have you already used it to raise financing?
Yes No
If yes, from whom?

Have you approached or are you working with any other organization?
Yes No
If so, which organization?

Is a confidentiality/non-disclosure agreement required for further evaluation of the project?
Yes No

Do you have an understanding of the following areas as they apply to your innovation?
Market opportunity Yes No
Finance required Yes No
Technology Yes No

Please add any directly relevant information here:

Equal Opportunity Monitoring

ETSU is committed to equal opportunities. In order that it can be effective we need to obtain information from people who apply for assistance. It is only for this reason that you are asked to complete the box below. The information you give will be used for statistical purposes only and will be treated in the strictest confidence.

Female Male

Age range:
17-19 20-29 30-39 40-49 50-59 60+

Ethnic Origin:
African American Asian Caucasion Hispanic Native American Other
If Other , please specify

Do you consider yourself to have a disability? Yes No
If so, what is the nature of your disability?

Thank you for helping

I agree the information contained herein is true to the best of my knowledge.

Type "Agree"