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(Information will be held in confidence and used only for evaluation for admittance to the UTP Incubator)
IMPORTANT NOTE: Submitting the following online application transmits your information through a standard email system. It is not a secure transmission. Information entered on the form may be viewed by others in transit. To apply for Incubator space while ensuring your information is transmitted privately, please print out, complete and fax or mail the PDF version of this application.
 
Business Name
Taxpayer ID #
Current Business Address
City
  State       Zip Code
 
E-mail
Website URL
Date Formed
Registered with Secretary of State? Yes     No
Business Structure
Individual Corporation
Partnership Limited Liability Co.
Non-Profit Org. Sub S Corporation
Principal Business Owner(s)
Name
Address
City
State     Zip
Phone
E-mail
Ownership %
 
Name
Address
City
State     Zip
Phone
E-mail
Ownership %
 
Management Team
Name
Address
City
State     Zip
Phone
E-mail
Position
 
Name
Address
City
State     Zip
Phone
E-mail
Position
 
Board of Directors
Name       Phone       E-mail  
Name       Phone       E-mail  
Name       Phone       E-mail  
Name       Phone       E-mail  
Business Description
 
Summary of Intellectual Property Position
 
Summarize your Market(s), including Market Strategy (if available)
 
Who are your Competitors?
Employees
Current Full-Time       Part-Time  
Projected in 2 Years Full-Time       Part-Time  
 
Do you have a Business Plan?     Yes     No
Services Needed
In order of priority, list the kinds of expertise, guidance, or support your company would seek from the UTP Technology Incubator or External Resources?
1.  
2.  
3.  
4.  
5.  
6.  
7.  
References
Trade References
Name       Company       Phone  
Name       Company       Phone  
Name       Company       Phone  
Current Bank
Bank Officer
Services Provided Checking     Savings     Loan
  Line of Credit     Investment
Accountant Name Firm   Phone  
Lawyer Name Firm   Phone  
Attachments
To the extent available, please send hard copies of the following documents via U.S. Mail or other courier.

•  Articles of Incorporation
•  Current Business Plan or Preliminary Draft
•  Resumes of Current Officers
•  Copy of Most Recent Financial Statement and Current Interim Financial Statement

Please Send to:
Daniel F. Marselle
Associate Director for Technology & Business Services
University Technology Park at IIT
10 West 35th Street, Suite 10F3 -1
Chicago , IL 60616
312-567-3900
312-567-3911 fax
marselle@utp.iit.edu
Certification
By checking this box, I certify that all the information contained in this application is true and complete.  I authorize the UTP Incubator to verify the information contained in this application by contacting bank, trade and other sources.  You may exchange with or furnish information to others regarding your credit experience with me and I agree to release you from all liability that may result.  I understand that this application, when submitted becomes the property of the UTP Incubator and that the application will be retained by the Incubator whether or not my application is approved.  I also understand that the information contained in this application will be used only to determine my eligibility for the incubator and not disseminated beyond the incubator staff and board of advisors without my written approval.

Applicant Name and Title       Date  
_________________________________________________________________________________________
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