Name of Person Submitting Application * Email * Phone Company Information
NOTE: For open ended questions, you may instead attach an Executive Summary (MAXIMUM OF 3 PAGES) from your business plan. In which case, please enter "See Executive Summary" in the space alloted.
Company Name and Description * Brief History of the Company * Is your company linked to the University of Tennessee or Oak Ridge National Lab? If so, how? If not, are you interested in forming a collaboration?
Example: Have licensed a technology from UT or ORNL, sponsoring research at UT or ORNL, one of the principals is from UT or ORNL, etc. — OR do you have an idea of how you would like to collaborate?
Facility Requirements: (check all that apply) * Describe any special ventilation, electrical or water requirements: Will you produce any hazardous waste that will require disposal? * If you responded yes to the question above, please list types of material and estimated quantities per month. * Company Status: (check all that apply) If funding in place, list sources: Tax ID No. Technology and Intellectual Property: Describe your technology (not the actual products) and what the technology does (NOT how it works) in plain English: * Describe additional developments, including technical breakthroughs, needed to bring this technology to the market: * Business Model Describe how your company will make money (i.e., the different types of revenue you will receive): * Management Team
List their names, their roles and how much of the company they own. Attach a single file containing a short resume or bio for each team member at the end of this document.
List Management Team:
Example: John Doe, CEO, 15% ownership, 10% dedicated to company
Describe any management assistance you think you will need: Strategic Partners Describe any technical, financial, legal or business development partners critical to your success: Benchmarking Information:
This information is used by UTRP to measure the economic impact of the program. All information will be kept strictly confidential and ONLY aggregate information of our total client base will be provided to our funding sources.
Number of Employee's * Total monthly payroll in dollars (USD): * Submit Application Today's Date *