Please include the following information with your submission:

Company name

Corporate structure (if applicable)

CEO

Lead contact person

Address

City

State

Email

Telephone

Website (optional)

Description of your business concept (in 200 words or less) (required)

Amount of capital currently seeking (numbers only)

Amounts and sources of capital raised to date (if applicable)

Current equity investors, if any, and amounts raised from each

Required verification