Entrepreneurs Intake Form

Name*
First Last
Email*
Phone*
Company Name
Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Company Phone
Company Website
Company Industry*
Is this a new or existing business?*
- New
- Existing
Is this company (check all that apply)
- Minority Owned
- Veteran Owned
- Woman Owned
- Student Owned
Describe your product or service in 200 characters or less
Do you have a prototype or have you demonstrated this concept?
- Yes
- No
Is the business already selling its product or services?
- Yes
- No
Does the company (versus an individual) own, have any exclusive licenses(s) to, or rely on intellectual property such as patents, copyrights or trademarks?
- Yes
- No
How did you hear about us?*
- Website
- Email
- Facebook
- Friend/Family
How can Breakthrough 307 help? (select all that apply)*
- Business Plan Development
- Funding
- Site Opportunities
- Advisory Services
- Connections
- Other
Would you be willing to attend forums to meet other entrepreneurs and like-minded people?*
- Yes
- No
If so, Check your preference on time/format
- Breakfast
- Dinner
- Lunch
- Evening w/refreshments
- Meeting only - no food/refreshments
- No preference
If you are interested in attending special programs, what topics would you like to see presented?
Anything else you would like us to know?
Phone
This field is for validation purposes and should be left unchanged.