HCDC Business Center CoWorks Application Form

1
Company Name* This field is required.
2
Name* This field is required.
First Name
Last Name
3
Email* This field is required.
4
Phone Number* This field is required.
5
Federal Employer Identification NumberIf none, leave blank
6
Current Business Address (if applicable)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Date Company was Established* This field is required.
Date
Month
Day
Year
8
Business Structure* This field is required.
Sole Proprietor
Partnership
C Corporation
S Corporation
Limited Liability Partnership
Limited Liability Company
9
Social MediaLeave blank if no social media
Facebook URL
Twitter Handle
LinkedIn URL
Other
10
WebsiteLeave blank if no website
11
Business Owned By* This field is required.
Female 100%
Male 100%
Female at least 51%
Male at least 51%
12
Minority Owned Business* This field is required.
YESNO
13
Last Fiscal Year Revenue* This field is required.
Type "0" if none
14
Monthly Payroll* This field is required.
Type "0" if none
15
Number of Current Employees* This field is required.
Full Time (Include Owners)
Part-time
Contract Employees
Total Employees - should be total of Full, Part-time, & Contract
16
Number of Team Members that will Utilize CoWorks Space?
17
Ownership Information* This field is required.
Owner #1 Name
Title
Email Address
Phone #
% Ownership
18
Additional Ownership InformationIf applicable - leave blank if no additional owners
Owner #2 Name
Title
Email Address
Phone #
% Ownership
19
Additional Ownership InformationIf applicable - leave blank if no additional owners
Owner #3 Name
Title
Email Address
Phone #
% Ownership
20
Company Description* This field is required.
50 words or less
21
Is the solution or product patent protected or do you intend to protect at some point?* This field is required.If yes, please describe
Yes
No
22
Please Describe Patents* This field is required.
23
What Stage of Development is Your Business?* This field is required.Check all that apply
Ideation
Minimum Viable Product
Operational - less than 1 year
Operational - more than 1 year
Paying Customers
Scaling
Successful Capital Raise
24
The Problem* This field is required.What are you solving?
0/150
Huge
Large
Normal
Small
Ok
Ok
25
The Solution* This field is required.Why is it unique or revolutionary? What is your value proposition?
0/150
Huge
Large
Normal
Small
Ok
Ok
26
The Market* This field is required.Why is it the right time and who is your customer? Who are your partners? What does the competition look like? What is the size of the opportunity? Do you (or teammate) have experience in that market or industry?
0/150
Huge
Large
Normal
Small
Ok
Ok
27
The Revenue Model* This field is required.How are you going to make money?
0/150
Huge
Large
Normal
Small
Ok
Ok
28
The Team* This field is required.Why can you and your team execute? What makes the founders tick? What are the unique strengths that each member brings to the team?
0/150
Huge
Large
Normal
Small
Ok
Ok
29
Success* This field is required.What does success look like for your company? What milestones do you want to achieve - short-term and long-term?
0/150
Huge
Large
Normal
Small
Ok
Ok
30
The Ask* This field is required.Why do you want to work with the HCDC Business Center?
0/150
Huge
Large
Normal
Small
Ok
Ok
31
Business Plan or Executive Summary Upload - Optional
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
32
Your Top 5 Needs from a Coach* This field is required.Pick 5. All are important, but we need your Top 5 to be effective.
Business Plan, Business Plan Implementation
Funding, Access to Capital
Sales, Traction, Outreach
Community Connections, Partnership Development
Marketing, Public Relations
Market Research
Financial Analysis
Legal (IP, Business Structure, etc)
SBIR
Grant Writing
Product Development
Human Resources
Administrative
Ownership Structure and Board
33
What membership level are you considering?* This field is required.Based on # of employees that will leverage the program.
1 Employee - $150/month
2 Employees - $200/month
3 Employees - $250/month
Not sure yet
34
What other optional amenities are you considering?* This field is required.Remember, membership amenities include WiFi, Business Coaching, Free Parking, Receptionist services, Pantry, Kitchen, microwave, fridge, coffee, Fax, Scanner, Printer, Notary service, Janitorial services, 24 hours / 7-day on-demand access to CoWorks Space (24/7 Access card security deposit $20.00 per user)
USPS Mailbox - $25
Secured locker - $15
Conference Room Usage - $20 per additional hour
BW Copies - .06 per page
Color Copies - .50 per page
Administrative Support - $20/hr
Key Card Replacement - $20
Don't know yet - I'll let you know later if I require one of these extra services
35
How Did You Hear About the CoWorks Program?* This field is required.
Social Media
Event
Web
Word of Mouth
Print
TV, Radio
36
Signature* This field is required.The information in this HCDC, Inc. & Hamilton County Business Center Inc. application is provided for the purpose of applying for tenancy to the HCDC Business Center. The information is accurate to the best of the applicant’s knowledge. The applicant understands that personal and / or business information may be requested pursuant to this application and hereby grants consent for such information to be provided to HCDC, Inc. & Hamilton County Business Center Inc. The applicant understands that HCDC, Inc. & Hamilton County Business Center Inc. retains sole decision whether this Application is approved, disapproved or modified.Completion and submission of the application by the applicant to the HCDC, Inc. Business Center is merely a request for entrance and shall not be construed as an approval or a commitment by the HCDC, Inc. & Hamilton County Business Center Inc. to rent space to applicant.The applicant agrees to hold harmless the HCDC, Inc. & Hamilton County Business Center Inc., its staff, employees, agents, volunteers, officers, and trustees from any and all claims, injury, cause of action whatsoever, whether previously, now or hereafter incurred, from any acts or omissions by the HCDC, Inc. & Hamilton County Business Center Inc., its staff, employees, agents, volunteers, officers, and trustees pursuant to any technical assistance provided.The applicant agrees that the HCDC, Inc. & Hamilton County Business Center Inc. assumes no responsibility for the success or failure of the applicant’s existing or proposed business venture. The role of the Business Center is consultative in nature and any advice or information offered may or may not be used per the applicant’s discretion. Therefore, the applicant releases the HCDC, Inc. & Hamilton County Business Center Inc. and its staff, employees, agents, volunteers, officers, and trustees from any liability associated with the applicant’s existing or proposed business venture. Additionally, I grant permission to HCDC, Inc. the unrestricted right to reproduce the photographs and/or video images taken of me for the purpose of publication, promotion, illustration, advertising, or trade in any manner or in any medium. Furthermore, I grant permission to use my statements that were given during HCDC events with or without my name, for the purpose of advertising and publicity without restriction.
Clear
37
Signature Date* This field is required.
Date
Year
Month
Day
38
Tags
Todo
In Progress
Done
Should be Empty: