Application – The Nussbaum Center for Entrepreneurship

Associate and Program Application - The Nussbaum Center for Entrepreneurship

This application must be completed in its entirety for prompt consideration for Office Space or Program Participation. This includes submission of a Business Plan and Financials or Financial Projections for your business. Additional information may be requested as part of the application process. Proprietary information will be treated as confidential. Incomplete applications will not be processed. Completion of this application does not guarantee residency in the incubator.

Company Information
Please provide information about your compnay.
Name of Company*
Please provide the FULL name of your company.
Name of contact completing this application*
Please provide the first and last name of the person completing this application.
First Last
ITEM A
Primary Contact
Should a Service Agreement be ratified, who will be responsible for the applicant company’s operations at The Nussbaum Center for Entrepreneurship?
Full Name*
First Last
Title*
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone*
(###) ###-####
Secondary Contact
Should a Service Agreement be ratified, who will be responsible for the applicant company’s operations at The Nussbaum Center for Entrepreneurship?
Full Name
First Last
Title
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone
(###) ###-####
Who will be legally responsible for the Service Agreeement if one is ratified?*
Please provide information about the person and/or entity that will be legally responsible for the Service Agreement.
What are your company's operations?*
Describe your company’s operations that you propose to locate at NCE by checking the appropriate answer(s).
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Description of Product(s)
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Description of Service(s)
The company proposes to have at The Nussbaum Center for Entrepreneurship Site:*
- Administrative Office
- Manufacturing Plant
- Kitchen Space
- Assembly Plant
- Service Center
- Distribution Center
- Research and Development Center
- Employee Training Center
- Other (Please describe)
- No Space Needed
Please describe
Initial Capitalization of your business:*
- 0 - $50,000
- $50,000 - $100,000
- $100,000 - $150,000
- over $150,000
ITEM B
Please tell us more about your company structure.
How is your company structured?*
(Check one)
- Sole Proprietorship
- Incorporated
- Partnership
- Other
How many years has the business filed tax returns?
Which state(s)?
Please list the abbreviation for all states.
On what date?
mm/dd/yyyy
Month
Day
Year
What year did you first file with the IRS as a partnership?
yyyy
List all officers:
Please list one FULL NAME per line.
Present address of your company:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Business Contact Number ONE:*
Land line, cell phone or fax - (###) ###-####
Business Contact Number TWO:
Land line, cell phone or fax - (###) ###-####
Federal Tax ID Number:*
E-mail Address:*
Professional Assistance Required
(Check all that apply)
- Insurance
- Marketing
- Accounting
- IT
- Legal
- Human Resources
- Financing
- NC Idea Grant Writing Program (Feb and Aug)
ITEM C
What are your site criteria?*
- Office Space
- Industrial or Lab Space
- Both
- No Space Needed
How much space do you need?
List the office equipment that you will have on site:
List your other criteria: (Internet, Copier, Fax etc.)
How many square feet?
List your capacity for:
1) Electricity
2) Natural Gas
3) Water/Sewer
List the machinery that will be used:
List your other criteria: (Wet Lab, Loading Dock, High Voltage, Compressed Air etc.)
List any flammable, volatile, toxic chemicals or other hazardous materials you propose to use on site at any time:
All Hazardous waste must be disposed of in accordance with North Carolina and Federal regulations. List details of your Hazardous waste disposal methods:
Define your reason for selecting The Nussbaum Center for Entrepreneurship.
When do you desire to execute a Service Agreement (should one be ratified)?
When do you anticipate needing additional space?
How many employees will be on site initially?
Projected number of employees to be on site at the end of the year?
ITEM D
List three credit or business references, which may be contacted on a confidential basis.
Reference ONE
Type of Reference (Bank or Credit)
Reference TWO
Type of Reference (Bank or Credit)
Reference THREE
Type of Reference (Bank or Credit)
Bank Reference #1
Bank name:
Principal contact:
First Last
Phone number:
Account Type:
- Business
- Personal
Bank Reference #2
Bank name:
Principal contact:
First Last
Phone number:
Account Type:
- Business
- Personal
Credit Reference #1
Business name:
Principal contact:
First Last
Phone number:
Account Type:
- Business
- Personal
Credit Reference #2
Business name:
Principal contact:
First Last
Phone number:
Account Type:
- Business
- Personal
A business plan should answer the following five questions:
- What is your business? ( How do you define your business)
- What is your product and/or service?
- Who is your customer?
- What is your marketing method? (Word of mouth, internet, direct mail, etc.)
- Financials: ATTACH FINANCIALS. PLEASE INCLUDE THE FOLLOWING:
  - Revenue
  - Cost of Goods Sold
  - General Administrative Costs ( rent, salaries, etc.)
  - Interest Expense ( if you are operating under a loan)
  - Profit/ Loss
REQUIRED for all applicants: Please upload your business plan. Incomplete applications will not be processed.
Max. file size: 512 MB.
Do you require assistance to complete Plan?*
A written Business Plan is required before approval.
REQUIRED for all applicants: Please upload your financials including income statement and balance sheet. If you are pre-revenue, please provide projections. Incomplete applications will not be processed.
Max. file size: 512 MB.
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Current Household Income for United Way Strategic Partner Grant.
As a United Way Strategic Partner, we are collecting this information to assist them in achieving their BOLD GOAL of lifting 3000 individuals out of poverty by the year 2030.
Current Household Income. Choose one.
- Less than $20,000
- $20,000 to $34,999
- $35,000 to $49,999
- $50,000 to $74,999
- $75,000 to $99,999
- Over $100,000
How did you hear about the NCE?*
In what ways do you expect to benefit through an association with The Nussbaum Center for Entrepreneurship?*
Submission of this application is only to allow The Nussbaum Center for Entrepreneurship to consider offering a Service Agreement for Office Space and/or extending services to the listed applicant. In no way does the issuance of an application guarantee that a Service Agreement will be extended and/or ratified. Data may be extracted for statistical compilation purposes. The Nussbaum Center for Entrepreneurship makes the final determination on applications and Service Agreement ratifications.
Acknowledgement
I have completed this application in its entirety and certify to its accuracy and release this information to The Nussbaum Center for Entrepreneurship.
Signator's Name
Type your FULL NAME as your signature
Signator's Title
Signature Date
MM slash DD slash YYYY
CAPTCHA
Untitled
- First Choice
- Second Choice
- Third Choice
Name
This field is for validation purposes and should be left unchanged.

Associate and Program Application - The Nussbaum Center for Entrepreneurship

Company Information

ITEM A

Primary Contact

Secondary Contact

ITEM B

Professional Assistance Required

ITEM C

ITEM D

Bank Reference #1

Bank Reference #2

Credit Reference #1

Credit Reference #2

A business plan should answer the following five questions:

Acknowledgement