Return to UTRF Business Incubator Main Page Name of Person Submitting Application* First Last Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone Number*Company 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 allotted.Company Name and Description*Brief History of the Company*How is your company linked to the University of Tennessee?*Example: Have licensed a technology from UT, sponsoring research at UT, one of the principals is from UT, etc.Facility Requirements: (check all that apply)* Office space Manufacturing space Laboratory space Access to water for operation Special ventilation Special electrical requirements Square Footage RequirementExample: 250 sq/ftDescribe any special ventilation, electrical or water requirements:Company Status: (check all that apply) Concept only Future funding needed Proof of concept complete Market research available Business plan available Management team in place Funding in place If funding in place, list source:If future funding needed, list strategy:Legal Structure:* C Corporation S Corporation LLC Partnership Sole Proprietor Other Date Formed: Tax ID No.NAICS Code: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:*Select one of the following:* This is a single-product idea or a platform technology This product has the potential to create new products across different markets Check all that apply: Patent(s) pending or allowed We have an exclusive license Copyright pending Patent(s) awarded We have a non-exclusive license Copyright in place Business ModelDescribe how your company will make money (i.e., the different types of revenue you will receive):*MarketingDescribe the market for this product (industry segment, types of customers, size of the market in dollars):*Describe the problems they are experiencing that your product will solve:*Describe how your solution solves these problems better than anything else that exists in the market:*Describe the top three competitors for your business:*Describe what distribution channels you will use to get this product/service to your customers:*Products and ServicesDescribe your products and services in non-technical terms*Manufacturing I plan to manufacture this product in-house. I plan to outsource the manufacturing of this product. I plan to develop this product and then license it. to someone else for production This is a service business. 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 companyIf your real strength is technology, would you be willing to consider delegating management responsibility to someone else? yes no If yes, under what conditions, if any?Describe any management assistance you think you will need:Principals/PartnersList other key stakeholders. Please list their names, their roles (e.g., founder, investor, shareholder, advisor) and how much of the company they own:List Principals/Partners: Example: Jane Doe, founder, 10% ownershipStrategic PartnersDescribe any technical, financial, legal or business development partners critical to your success:Benchmarking Information:This information is used by UTRF and CEG 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 Employees*Total monthly payroll in dollars (USD):*Total annual sales in dollars (USD):*Total investments received to date in dollars (USD):*Total sponsored research dollars (USD) received to date:*Submit ApplicationAttach Executive Summary (optional) Drop files here or Management Team Resume and/or Bios* Drop files here or Today's Date* 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. CommentsThis field is for validation purposes and should be left unchanged.