Advise Request Form

Please complete the ADVISE Request Form below to be considered for an investment from JumpStart. If we determine there is a potential fit, you will be contacted within one week to schedule an ADVISE session.

Advise Request Form * Title: * First Name: Middle Name: * Last Name: * Company Name: * Job Title: * Address: * City: * State/Province * Zip:
(You must provide your zip+4 code. If you do not know the additional 4 digits of your zip code, you can look them up by clicking here.) * Phone Number:
(Please use the format xxx-xxx-xxxx) Cell Phone Number:
(Please use the format xxx-xxx-xxxx) Fax Number:
(Please use the format xxx-xxx-xxxx) * County: * Email Address: Website:

Is your company minority-owned or managed?Yes
No

If yes, please specify Minority Group:

Is your company female-owned or managed?YesNo

* Basic Company Category: * What product or service does your company sell (or expect to sell)? What is different or unique about your product or service? (100 words or less)

* JumpStart only funds businesses located in Northeast Ohio. Are you located in Northeast Ohio or will you agree to locate here as needed? Yes
No

* Are you interested in pursuing a high-growth business strategy (i.e. creating a business model designed to achieve $30-$50 million in revenues within the next five years) which may involve raising money from outside sources, including venture capital funds? Yes
No
Not Sure

* Are you willing to have your percentage ownership of the company decrease as a result of taking on additional investment capital? Yes
No

* How much cash has been invested in the business to-date? (Do not include foregone salaries or in-kind contributions.)

Source(s)? (Select all that apply.) Angel Investor Bank Friends and Family Self Venture Capital Fund Other (please specify)

* JumpStart investments average around $300K and are expected to last a minimum of one year. Is this in keeping with your expectations? Yes
No If no, how much money are you seeking?

* If your company relies on intellectual property ("IP") such as patents or trademarks for its competitive advantage, does the company (versus an individual) own or have exclusive license to the IP? Yes
No
N/A

Feel free to elaborate on your IP situation here: (100 words or less)

* If JumpStart enters into due diligence on your company we will ask for access to the company’s legal documents (including patent or license information) and will ask to contact many of your collaborators, customers (or potential customers) and personal references. Is this something you will agree to? Yes
No
Not Sure

How did you hear about JumpStart? Please specify:

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JumpStart Inc. 737 Bolivar Road Suite 3000 Cleveland, Ohio 44115

P 216.363.3400

F 216.363.3401

Email ask@jumpstartinc.org

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