Connections Intake Form

Name
First Last
Company Name
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Select all of the following industries with which you have significant experience.
What category best describes your profession (check all that apply)?
Which of the following roles do you want to play in the company(s) that you choose to assist?*
- Active role in management
- Board of Directors/Advisers
- Passive (mentor/adviser)
How many companies do you want to be involved with assisting?
Check all of the following stages of development of companies with which you would consider investing.
- Start-up
- Re-start
- Early
- Expansion
- Turnaround
- Re-Capitalization
- Buyout
- Franchise
- Other
Have you participated in a network like Breakthrough 307?
- Yes
- No
Would you be willing to sign a confidentiality agreement with entrepreneurs?*
- Yes
- No
Would you attend private forums to meet with entrepreneurs?
- Yes
- No
If so, check your preference on time/format.
- Breakfast
- Dinner
- Meeting only - no food/refreshments
- Lunch
- Evening with refreshments
- No preference
How did you hear about us?*
- Website
- Email
- Facebook
- e2e
- Friend/Coworker
Phone
This field is for validation purposes and should be left unchanged.