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

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:

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?

Please indicate sources of investment(s): (check all that apply) Owner/Founder Grants Friends and Family Angels Venture Capital Sales Revenue Loans None Other (please specify)

* 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? YesNo

* 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:

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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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