Application

ITEM A

Primary Contact

Should a lease 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 lease 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 lease if one is ratified?*

Please provide information about the person and/or entity that will be legally responsible for the lease.

What are your company's operations?*

Describe your company’s operations that you propose to locate at NCE by checking the appropriate answer(s).

Description of Product(s)

Description of Service(s)

The company proposes to have at The Nussbaum Center for Entrepreneurship Site:*

Manufacturing Plant
Assembly Plant
Service Center
Distribution Center
Administrative Office
Research and Development Center
Employee Training Center
Other (Please describe)

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

MM

DD

YYYY

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

Do you require assistance to complete Plan?*

A written Business Plan is required before approval.

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 as a site:

When do you desire to begin a lease (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

If you have a business plan, please upload

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 leasing space and/or extending services to the listed applicant. In no way does the issuance of an application guarantee that a lease proposal 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 lease 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

Comments

This field is for validation purposes and should be left unchanged.

Associate 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

The Nussbaum Center for Entrepreneurship