Contact Information - PDF document

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4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Contact Information: Company NameKey ContactMailing AddressCityZipState/ProvinceMain PhoneCellFaxEmailWebsiteName Title Name Title Company Overview: Pleasecompletetheformbest Desired Move-In Date Anticipated Exit (Date) Company Type Industry Sector Management Team: Tenant Application Form Please provide a concise description of your business below (e.g. the Executive Summary of your business plan, including your product/service description). Doing Business As (DBA) Sole Proprietorship LLP / LLC C-Corporation S-Corporation CTech IncUBator Tenant Application Form Technology: Market Description and Competitive Analysis: Please describe the market (customer) your company intends to address with its products and/or services. Be sure to indicate market size and growth trends, as well as existing and potential competition. Please provide a non-confidential description of your product and/or technology. How does the differentiating feature(s) of your product/service constitute a competitive advantage? CTech IncUBator Tenant Application Form Funding Source Founder's Contribution Loans Investment Capital SBIR/STTR Other Total [Add Manually] Summary P&L RevenuesExpenses Net Profit/Loss [Add Manually] Type ManagementR&DManufacturingAdministrativeOther Total [Add Manually] Additional Resources: Please indicate which UB, CI, and/or sponsor resources may be of interest to you: Employment Projections (enter actual years, as may be appropriate) Financial Projections (enter actual years, as may be appropriate) Summary Profit & Loss (enter actual years, as may be appropriate) If other, please specify: Library Faculty Access Research Collaborations Student Interns Recreation Center SCORE Pre-Seed / Seed Funding (CI) Pro Bono Professional Services e.g. Legal, Tax, Accounting, IP, Other: CTech IncUBator Tenant Application Form 1.      Company Direction and

2 Objectives 2.      Technology/Prod
Objectives 2.      Technology/Product 3.      Market Potential, Company Size & Growth Potential, Industry Size & Growth Potential 4.      Management Background and Experience 5.      Financial and Business Plans 6.      Anticipated Collaboration(s) and UB and/or CI Linkages & Synergy 7.      Interest and Willingness to Participate in Educational Programming The CTech IncUBator requires participation in at least 60% of the workshops, events and seminars scheduled for tenant companies. Please list the types of programming or topics that your company would find beneficial: Please describe any existing relationships or potential linkages between your company and the University of Bridgeport and/or Connecticut Innovations: Applications will be reviewed with consideration given to the following: CTech IncUBator Tenant Application Form Title:Company: Signature:Date:Address:Telephone:E-mail: Email Addressgadselig@bridgeport.edu "OR" Mail To: University of Bridgeport, Mandeville Hall, Room 302 230 University Avenue Bridgeport, CT 06604 Tel: 203-576-4870 Received Date: Reviewed by CI: Reviewed by UB: Disposition: Applicant Notified: Comments Please Return To: Dr. Gad J. Selig, INTERNAL USE ONLY - CI & UB TheundersignedauthorizesconsentsUniversityBridgeportand/orConnecticutInnovations,Inc.,itssuccessorsassigneesaccessvarioussourcesinformationdeemsappropriate,butnotlimitedbusiness/consumercreditreports,professional/personalreferences,etc.TheundersignedexecutingthisformherebyagreesholdharmlesstheUniversityBridgeportConnecticutInnovations,Inc.,itssuccessorsassigneeswithrespecttheprocurementof any and all credit, character, and financial intelligence. The applicant agrees to pay for the background check. Iherebycertifythat,thebestknowledge,theforegoinginformationaccuratecomplete.IfurthercertifythatI will report, in writing to the CTech IncUBator any changes to the information contained herein. Name Nam

3 e Date Date Date ACCEPT REJECT CTech Inc
e Date Date Date ACCEPT REJECT CTech IncUBator Tenant Application Form 10/07/2015 4 4 4 4 4 4 Title:Company: Signature:Date:Address:Telephone:E-mail: Email Addressgadselig@bridgeport.edu "OR" Mail To: University of Bridgeport, Mandeville Hall, Room 302 230 University Avenue Bridgeport, CT 06604 Tel: 203-576-4870 Received Date: Reviewed by CI: Reviewed by UB: Disposition: Applicant Notified: Comments Please Return To: Dr. Gad J. Selig, INTERNAL USE ONLY - UB TheundersignedauthorizesconsentsUniversityBridgeportand/orConnecticutInnovations,Inc.,itssuccessorsassigneesaccessvarioussourcesinformationdeemsappropriate,butnotlimitedbusiness/consumercreditreports,professional/personalreferences,etc.TheundersignedexecutingthisformherebyagreesholdharmlesstheUniversityBridgeportConnecticutInnovations,Inc.,itssuccessorsassigneeswithrespecttheprocurementof any and all credit, character, and financial intelligence. The applicant agrees to pay for the background check. Iherebycertifythat,thebestknowledge,theforegoinginformationaccuratecomplete.IfurthercertifythatI will report, in writing to the CTech IncUBator any changes to the information contained herein. Name Name Date Date Date ACCEPT REJECT CTech IncUBator Tenant Application Form 10/07/2015 1.      Company Direction and Objectives 2.      Technology/Product 3.      Market Potential, Company Size & Growth Potential, Industry Size & Growth Potential 4.      Management Background and Experience 5.      Financial and Business Plans 6.      Anticipated Collaboration(s) and UB and/or CI Linkages & Synergy 7.      Interest and Willingness to Participate in Educational Programming The CTech IncUBator requires participation in at least 60% of the workshops, events and seminars scheduled for tenant companies. Please list the types of programming or topics that your company would find beneficial: Please describe any existing relationships or potential lin

4 kages between your company and the Unive
kages between your company and the University of Bridgeport and/or Connecticut Innovations: Applications will be reviewed with consideration given to the following: CTech IncUBator Tenant Application Form Funding Source Founder's Contribution Loans Investment Capital SBIR/STTR Other Total [Add Manually] Summary P&L RevenuesExpenses Net Profit/Loss [Add Manually] Type ManagementR&DManufacturingAdministrativeOther Total [Add Manually] Additional Resources: Please indicate which UB, CI, and/or sponsor resources may be of interest to you: Employment Projections (enter actual years, as may be appropriate) Financial Projections (enter actual years, as may be appropriate) Summary Profit & Loss (enter actual years, as may be appropriate) If other, please specify: Library Faculty Access Research Collaborations Student Interns Recreation Center SCORE Pre-Seed / Seed Funding (CI) Pro Bono Professional Services e.g. Legal, Tax, Accounting, IP, Other: CTech IncUBator Tenant Application Form Technology: Market Description and Competitive Analysis: Please describe the market (customer) your company intends to address with its products and/or services. Be sure to indicate market size and growth trends, as well as existing and potential competition. Please provide a non-confidential description of your product and/or technology. How does the differentiating feature(s) of your product/service constitute a competitive advantage? CTech IncUBator Tenant Application Form Application Date Contact Information: Company NameKey ContactMailing AddressCityZipState/ProvinceMain PhoneCellFaxEmailWebsiteName Title Name Title Company Overview: TheCTechIncUBatortheUniversityBridgeport(the“CTechIncUBator”)entrepreneurialassistanceinitiativetheUniversityBridgeport(UB)ConnecticutInnovations(CI).TheCTechIncUBator’smissionhastenthegrowthinnovativestart-upearly-stagetechnologybasedcompaniesprovidingfacilities,supportexp

5 ertisehelpacceleratethegrowthcompanies.P
ertisehelpacceleratethegrowthcompanies.Potentialtenantcompaniesmustsubmitapplicationforinitialreviewthecompany’s fit and compatibility with the CTech IncUBator’s purpose, objectives, focus and facilities. Pleasecompletetheformbestyoucan.Pleaseattachanyadditionalinformationcoveredthisapplication and that you wish to bring to our attention. Desired Move-In Date Anticipated Exit (Date) Company Type Industry Sector Management Team: Tenant Application Form 250 Myrtle Ave, Bridgeport, CT 06604 Please provide a concise description of your business below (e.g. the Executive Summary of your business plan, including your product/service description). Doing Business As (DBA) General Partnership Sole Proprietorship LLP / LLC C-Corporation S-Corporation CTech IncUBator Tenant Application Form Title:Company: Signature:Date:Address:Telephone:E-mail: Email Addressgadselig@bridgeport.edu "OR" Mail To: University of Bridgeport, Mandeville Hall, Room 302 230 University Avenue Bridgeport, CT 06604 Tel: 203-576-4870 Received Date: Reviewed by CI: Reviewed by UB: Disposition: Applicant Notified: Comments Please Return To: Dr. Gad J. Selig, INTERNAL USE ONLY - UB TheundersignedauthorizesconsentsUniversityBridgeportand/orConnecticutInnovations,Inc.,itssuccessorsassigneesaccessvarioussourcesinformationdeemsappropriate,butnotlimitedbusiness/consumercreditreports,professional/personalreferences,etc.TheundersignedexecutingthisformherebyagreesholdharmlesstheUniversityBridgeportConnecticutInnovations,Inc.,itssuccessorsassigneeswithrespecttheprocurementof any and all credit, character, and financial intelligence. The applicant agrees to pay for the background check. Iherebycertifythat,thebestknowledge,theforegoinginformationaccuratecomplete.IfurthercertifythatI will report, in writing to the CTech IncUBator any changes to the information contained herein. Name Name Date Date Date ACCEPT REJECT CTech IncUBator Tenant Application Form 10/07/2015