Intake Form

Intake Form

Please answer the questions below by providing as much NON-CONFIDENTIAL information as possible, Doing so will help us in making an informed decision about whether we should meet with you to discuss representing your company. Although we ask you not to send any information you consider confidential, we will keep all of your information confidential. Please send this information to:intake@newtechenterprise.org his is a secure e-mail address.

BY SUBMITTING THIS INTAKE FORM TO THE CENTER FOR NEW TECHNOLOGY ENTERPRISE (?CENTER?) IN ANY MANNER WHATSOEVER, YOU HEREBY CONSENT TO THE CENTER?S FURNISHING THE INFORMATION ON THIS INTAKE FORM AND ANY ADDITIONAL INFORMATION THE CENTER RECEIVES FROM YOU -- REGARDLESS OF WHETHER YOU CONSIDER SUCH INFORMATION TO BE CONFIDENTIAL -- TO PARTICIPATING LAW FIRMS AND OTHER PARTICIPATING PROVIDEDRS, UNDER THE SAME OBLIGATIONS OF CONFIDENTIALITY THAT APPLY TO THE CENTER, SO THAT THEY CAN DECIDE WHETHER TO ACCEPT YOU AS THEIR CLIENT UNDER THE CENTER'S PROGRAM. THE CENTER WOULD FURNISH SUCH INFORMATION ONLY IF THE CENTER IS PREPARING TO ACCEDPT YOU AS A CLIENT.

Company Name *
Your Name * First Last
Position *
Address *

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Url *
Email *
Phone * - (###) - ### ####
Fax * - (###) - ### ####
Your Company/Business

Company or Business - related information
Have you established a business entity? * Yes No
If yes, Nature of entity: Sole Proprietorship Partnership LLC S-Corp C-Corp
If you selected Yes above please fill this portion out.
Date Established / MM / DD YYYY
State/Province Established *
What does your company offer? * Products Services Both Other
other (explain)

If you answered other in previous question please fill this out.
What features of your products/services would make potential customers want to pay for them? How will you induce them to do so? *
What are your core strengths? *
Do you have a business plan? * Yes No
If yes, please attach a NON-CONFIDENTIAL summary of the plan.
What is your company's capitalization? * greater then 1million less then 1million greater then 5 million less then 5 million
How many people work for your company?
Full time employees *
Part time employees *
What is the nature of invesment in your company? * Own money Friends and Family Grants from govt. agencies Angels VCs Corporate strategic partners Public
Are you looking for additional investors? * Yes No
If yes, from what sources?
Is your company currently generating revenue? * Yes No
What is your marketing strategy? *
Describe the types of customers you have or are targeting? *
Who are your present competitors? *
Who do you think can enter the market to compete with you? *
How high are the barriers to entry? What are they? *
What is your exit strategy, if any? *
Company Technology

In this section we will find out about your company's technology.
What would you consider as your company’s core technology? * Biotech Information Technology Other
If your technology area is Biotech, is it related to * Therapeutics Diagnostics Bioinformatics Medical Devices Other
If your technology is Information Technology, is it related to:* Wireless Communications Software Internet related Other
Is your technology proprietary?* Yes No
If Yes specify below
Proprietary specifics
Has it been developed in-house?* Yes No
Have you in-licensed any technology? * Yes No
If yes, from whom?
Do you have in-house counsel? * Yes No
Do you have relationships with any outside lawyer or law firm? * Yes No
If yes, please identify the lawyer of firm
Indicate what services the outside counsel provides to your company?* IP Business Litigation Other
Do you have any inventions for which you would like to obtain IP protection? * Yes No
If yes, would the IP be? * patents trademarks copyrights trade secrets
Do you need review or drafting of any agreements? * Yes No
If yes, what types?
Do you have any legal assistance concerning corporate or business matters? * Yes No
Have you established policies governing your company’s current or future IP assets? * Yes No
Do you think you need to train yourself or your management/employees about IP/Business, or governance matters? * Yes No
If yes, Please specify:
Other Needs

Please tell us a little more about your company.
Do you have any accountant? * Yes No
Do you have any other business/financial advisors? * Yes No
If yes, specify what types:
Do you have a Board of Directors or Board of Management?* Yes No
Do you have any advisory boards?* Yes No
If yes, what types?
Do you carry insurance for your Board of Directors/Management and Advisory Boards?* Yes No
If yes, what are the coverages?
What other types of services do you believe you need to enable your business to grow? Please specify:*
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