Entrepreneur Roundtable Membership Application

QUALIFICATION CRITERIA:
- Principle place of business is in Pasco County.
- Founders must be committed to participate monthly and “take time out of their business to work on their business.”
- Founders must be willing to listen and learn from peers.
- Generate less than $1 Million in annual revenue.
CORPORATE INFORMATION
Which location are applying for?:

Pasco Tech Business RoundtableDade CityNew Port RicheyWesley Chapel
Company Name*
Company Web Address:
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Full Name*

First NameLast Name
Title*
Title
Home Phone*

Area CodePhone Number
Business Phone

Area CodePhone Number
Cell Phone*

Area CodePhone Number
E-mail*
The goal of the program is to help Pasco based companies work more efficiently, become more strategic and create new job opportunities.
Please list the major products/service that you produce:
Is your company established?*

YesNo
If yes - when?
Number of year’s company has been in Pasco County:

1-56-1011-2020+
Primary Business Type:

ManufacturingDistributionProcessingTechnologyConstructionHealth/Human PerformanceScientific/Research
What is your total annual Pasco payroll (excluding payroll taxes and benefits)?
Is the company:

Veteran ownedWoman ownedMinority ownedShareholder ownedNot Applicable
Number of Employees:
Please indicate, by percentage of sales, where your customers are located: (should equal 100%
What were your total gross sales from the most recent fiscal year?
When does your fiscal year begin?
During the past year, have your company’s sales:

IncreasedDecreasedRemained the Same
Do you perceive your market share to be:

IncreasingDecreasingRemained the Same
Do you sell to the Federal Government or to a Prime Contractor of the Fed Gov?

YesNo
CONFIDENTIALITY STATEMENT

Pursuant to Section 288.075 of the Florida Statutes, I hereby request that any information contained herein concerning our plans, intentions or interest to locate, relocate or expand any of our business activities in this State be treated confidentially.
Signature

Clear
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