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Insight Park Application
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* Indicates required question
Company Name
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Your answer
Title
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Your answer
Email Address
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Your answer
Contact Person
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Your answer
Contact Person
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Your answer
Phone Number
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Your answer
Work Address
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Your answer
City
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Your answer
State
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Your answer
Zipcode/Postcode
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Your answer
Country
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Your answer
Has the company been incorporated?
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Yes
No
If your company is already incorporated, please enter the date it was incorporated (MMDDYYYY)
Your answer
State of incorporation
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Your answer
What is the legal form of your business?
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LLC
C-Corporation
S-Corporation
Partnership
Sole Proprietorship
Unincorporated
Number of employees today
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Your answer
Please estimate the number of employees in 3 years
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1 to 5
6-15
16+
Does the company have a business plan?
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Yes
No
In Progress
Briefly describe your business. What market need are you solving? What is the solution you are offering? Who are your target customers?
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Your answer
Do you hold proprietary rights (patents/licenses) for the technology you are developing?
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Yes
No
N/A
What will your monthly operating expense be for the first twelve months? (Include items such as rent, wages, inventory, phones, marketing, etc.)
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Your answer
How will you fund your operation for the next 12 months? (i.e. cash reserves, credit cards, investment, operating revenue, bank loan, grant, etc)
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Your answer
Have you secured any of the following to capitalize your business?
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Government grant/contract
Angel investment
Venture capital investment
Corporate partner investment
Self funded
Other:
Approximately how much space, in square feet, will you need?
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Your answer
What type of space do you need?
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Office
Lab
Other:
When do you anticipate you will need to occupy Insight Park space?
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Your answer
Will you be connecting any servers to the campus network from space in Insight Park? If yes, how many and for what purpose?
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Your answer
Will you be offering any Internet-based information services to consumers for a fee using systems hosted at Insight Park? If yes, please describe.
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Your answer
Do you anticipate needing to transfer very large amounts of data using network services provided by Insight Park? If yes, please describe.
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Your answer
If you will be conducting research that requires the use of any chemicals, please list them below. MSDS for each must be provided to Insight Park if your company is accepted.
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Your answer
Please indicate what information/service connections you may request from the incubator.
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Accounting
Legal
Marketing
Intellectual Property
None
Other:
Required
Please indicate if you have any of the following service providers.
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Bank
Attorney
Accountant
Marketing/PR Agent
Required
Are you interested in utilizing co-op students or student interns?
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Yes
No
Maybe
If so, in what capacity?
Your answer
If you have an existing relationship with a research at the University of Mississippi, please describe that relation and the activities taking place.
Your answer
My submission of this form certifies that all the information contained herein is true and complete.
*
True
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