Contact Information
Title: -None- Dr. Honorable Miss Mrs. Mr. Ms. Prof.
First Name:
Middle Name:
Last Name:
Suffix:
-None- Esq. III II IV I Jr. M.D. Ph.D. Sr. V
Company Name:
Job Title:
Address One:
Address Two:
City:
State:
- Select One - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New
Hampshire New Jersey New Mexico New York North Carolina North
Dakota Ohio Oklahoma Oregon Pennsylvania Rhode
Island South Carolina South
Dakota Tennessee Texas Utah Vermont Virgin
Islands Virginia Washington West Virginia Wisconsin Wyoming
Zip:
County:
- Select One - Allegheny Armstrong Beaver Butler Fayette Greene Lawrence Washington Westmoreland Other
Country Other County in PA Other State
in U.S.
Municipality:
-
Select County First -
Phone Number:
(
Fax Number:
(
E-Mail:
Web Site:
Additional Company Information
If you are from outside
the southwestern Pennsylvania region, why are you interested in locating
here?(3 sentences or less)
Abbreviated company
description: Describe key company
products and services. Emphasize differentiating characteristics.
Please attach your
business plan or executive summary:If
you do not yet have a business plan, leave this blank.
Company Legal Type:
- Select One - Not formed yet Corporation Non-profit Corporation Partnership Sole Proprietorship Sub-S
Corporation state
and date of
incorporation?
- Select One
- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY
(mm/dd/yyyy)
Number of full-time
employees: (total worldwide)
Management Team
1. Name:
Title:
2. Name:
Title:
3. Name:
Title:
Capital Investment to
Date
Amount: (in dollars)
Source:
(please specify)
Investment amount that
company is seeking from Innovation Works: (in dollars)
Other than capital,
what are your immediate resource needs?:
(please specify)
How did you hear about
Innovation Works?:
Have you had contact
with Innovation Works previously?:
Terms and Agreements
Innovation Works is a non-profit economic development agency serving the citizens of southwestern Pennsylvania. If we agree to provide you with business assistance, we will do so at no charge to you. We disclaim (and you waive) all warranties related to the assistance we may provide to you, and you also agree that neither Innovation Works, its directors, officers, employees nor agents shall be liable to you for any damages, including, without limitation, loss of profit or business opportunity.
