JumpStart Advisory Request Form

Advise Request Form

Contact Information

Title: First 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:

Please indicate the JumpStart Services for which you are interested:
(select all that apply)

Jumpstart Ventures

Jumpstart Inclusion Advisors

Business Information

Industry Categorization:

Provide a brief summary of your company/product/idea. Please indicate what is unique: (100 words or less)

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)

What operating stage is your company in? Imagining - Technology and business model are conceptual, not yet developed
Incubating - Technology and business model are in development, but products are not yet for sale
Demonstrating - Prototype technology can be shown and orders for product can be taken
Market Entry - Product shipping
Growth and Sustainability - Established business, plan to increase market share/revenue/profits

How much cash has been invested in the business to date? How much cash are you seeking at this time? (if none, please indicate)

Are you interested in pursuing a high-growth business strategy (i.e. creating a business model designed to achieve $30 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
N/A

Is your company minority-owned or managed? Yes
No

If yes, please specify Minority Group:

Is your company woman-owned or managed? Yes
No

Is at least one person working for the company on a full-time basis? Yes
No

How many full-time employees work for the company?

We only work with businesses located in Northeast Ohio. Are you located in Northeast Ohio or will you agree to locate here as needed? Yes
No

How did you hear about us? Please specify:

JumpStart

JumpStart Advisory Request

IdeaExchange Blog

Advisory Request Form

Contact Information

Business Information