The University of TennesseeResearch Park at Cherokee Farm 2730 Cherokee Farm Way, Knoxville, TN 37920 +1 865 974-8210 Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name of Person Submitting Application *FirstLastEmail *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhoneCompany InformationNOTE: 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) *Office spaceLaboratory spaceAccess to water for operationSpecial ventilationSpecial electrical requirementsSquare Footage RequirementExample: 250 sq/ftDescribe any special ventilation, electrical or water requirements:Will you produce any hazardous waste that will require disposal? *YesNo sources: types mentorship If you responded yes to the question above, please list types of material and estimated quantities per month. *Company Status: (check all that apply)Concept onlyFuture funding neededProof of concept completeMarket research availableBusiness plan availableManagement team in placeFunding in placeIf funding in place, list sources:Legal Structure: *C CorporationS CorporationLLCPartnershipSole ProprietorOtherDate Formed(MM/DD/YYYY)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 ModelDescribe how your company will make money (i.e., the different types of revenue you will receive): *Management TeamList 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 companyDescribe any mentorship or advisors you think you will need on your team:Strategic PartnersDescribe 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 ApplicationAttach Executive Summary (optional) Click or drag a file to this area to upload. Management Team Resume and/or Bios * Click or drag a file to this area to upload. Today's Date *(MM/DD/YYYY)Application Statement *I hereby certify that, to the best of my knowledge, the information provided herein is true and accurate. I am aware that any statements made by me that knowingly misrepresent the facts will result in the denial of my application.Submit
