Client Application Form

Name (President or CEO) ____________________________________________

Company Name _____________________________________________________

eMPLOYER ID. # and/or PERSONAL SS # _______________________

Address _____________________________________________________________

City, State, Zip_______________________________________________________

Phone ______________________________ Fax ____________________________

E-mail _______________________________________________________________

How is your business organized? (CIRCLE ONE)

1. Sole Proprietorship
2. Partnership
3. LLC
4. Corporation Type? __________________

IF THIS IS AN EXISTING BUSINESS:

1. DATE BUSINESS STARTED _______________________
2. WHERE STARTED _______________________________
3. WHAT STAGE OF DEVELOPMENT (CIRCLE ONE)
1. IDEA STAGE
2. EARLY STAGE.
3. PROTOTYPE STAGE (MANUFACTURED & SOLD IN SMALL QUANTITIES)
4. DEVELOPMENTAL STAGE (PRODUCT MATURITY, SALES VOLUME & MGMT CAPABILITY)
5. EXPANSION STAGE (CAPABLE OF STANDING ON YOUR OWN)

D. NUMBER OF EMPLOYEES FULL TIME _______ PART TIME _______

LIST THE NAME(S) AND TELEPHONE NUMBER(S) OF THE PRINCIPAL(S)

NAME TITLE PHONE % OWNED P/T or F/T

__________________ ___________ __________ __________ ________

__________________ ___________ __________ __________ ________

__________________ ___________ __________ __________ ________

__________________ ___________ __________ __________ ________

TYPE OF BUSINESS (CIRCLE ONE)

A. HIGH TECHNOLOGY

B. SERVICE

C. RETAIL

D. SOFTWARE

E. LIGHT MANUFACTURING

F. OTHER __________________________________

BRIEFLY DESCRIBE YOUR BUSINESS.

____________________________________________________________________________________________________________________________________________________________

BRIEFLY DESCRIBE YOUR PRODUCT OR YOUR SERVICE.

____________________________________________________________________________________________________________________________________________________________

DESCRIBE YOUR BUSINESS BACKGROUND OR EXPERIENCE WITH PRODUCT/ SERVICE.

____________________________________________________________________________________________________________________________________________________________

HOW IS YOUR PRODUCT UNIQUE?

____________________________________________________________________________________________________________________________________________________________

DESCRIBE YOUR TARGET MARKET AND MARKET SIZE.

____________________________________________________________________________________________________________________________________________________________

HOW CAN YOUR PRODUCT OR TECHNOLOGY BE PROTECTED?

A. PATENT

B. TRADEMARK or COPYRIGHT

C. TRADE SECRET

D. OTHER _______________________

WHAT IS THE PRIMARY SOURCE OF FINANCING FOR YOUR BUSINESS?

A. PERSONAL SAVINGS

B. OPERATING INCOME

C. EQUITY INVESTMENT

INFORMAL/PRIVATE _______ VENTURE CAPITAL _______

D. DEBT

PERSONAL _______ BANK _______

HOW WILL YOU REPAY INVESTORS?

______________________________________________________________________________

______________________________________________________________________________

CURRENT CAPITALIZATION OF YOUR BUSINESS (CIRCLE ONE)

A. $0-$50,000

B. $50,000-$250,000

C. $250,000-$500,000

D. OVER $500,000

ADDITIONAL NEAR-TERM CONTEMPLATED CAPITALIZATION

______________________________________________________________________________

TOTAL ASSETS _____________________________________

TOTAL REVENUE (PAST 12 MONTHS) ____________________________

ANNUAL GROWTH RATE (%) __________________________________

ESTIMATED EMPLOYMENT: DIRECT INDIRECT

CURRENT FULL TIME _____ PART TIME _____ _________

ONE YEAR LATER FULL TIME _____ PART TIME _____ _________

WITHIN 5 YEARS FULL TIME _____ PART TIME _____ _________

WHAT DO YOU CONSIDER ARE YOUR BIGGEST OPORTUNITIES AND NEEDS?

____________________________________________________________________________________________________________________________________________________________

DO YOU HAVE A BOARD OF ADVISORS? YES _____ NO ______

ARE YOU WILLING TO ACCEPT COUNSELING FROM A BOARD OF ADVISORS APPOINTED FOR YOU? YES _____ NO ______

INCUBATOR SERVICE REQUESTED (CIRCLE ONE)

A. RESIDENT (PLAN TO MOVE INTO THE INCUBATOR)

B. AFFILIATE (NON-RESIDENT USE OF THE SERVICES ONLY)

DESCRIBE WHAT YOU EXPECT THE INCUBATOR TO PROVIDE.

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

FOR INCUBATOR RESIDENTS, WHAT IS THE AMOUNT OF SPACE NEEDED?

OFFICE _______ SQ. FT.

LAB _______ SQ. FT.

LIGHT MANUFACTURING _______ SQ. FT.

OTHER ___________________ _______ SQ. FT.

HOW LONG DO YOU EXPECT TO BE IN VITEC2?

_____ 1 YR _____ 2 YR _____ 3 YR

HOW DID YOU HEAR ABOUT US?

______________________________________________________________________________

______________________________________________________________________________

CHECKLIST

THE FOLLOWING DOCUMENTS ARE ATTACHED:

_______ BUSINESS PLAN, INCLUDING MARKET STATISTICS, CONTRACTS.

_______ LIST OF OFFICERS, INCLUDING BRIEF BIOS

_______ SALES HISTORY OF YOUR PRODUCTS

_______ PATENTS

_______ PRODUCT LITERATURE, BROCHURES, PHOTOS

_______ CUSTOMER TESTIMONIALS, LETTERS OF SUPPORT

_______ CASHFLOW PROJECTIONS

_______ LIST OF CURRENT OR REQUIRED CAPITAL EQUIPMENT

I HAVE READ THE TENANT LEASE AGREEMENT AND CLIENT MANUAL AND AGREE TO THE TERMS THEREIN.

_________________________________ ________________________

APPLICANT SIGNATURE DATE

I certify that the above information is true and accurate and that Vitec² will retain this application whether approved or denied. I hereby authorize Vitec² to verify my credit history and employment and to release to any credit information agency any information regarding the credit experience with the signer, if applicable.

Confidentiality of the information gathered by Vitec² will be maintained as required under the Privacy Act.