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Clearwater's Virtual Incubator Program (VIP) Application

Fields marked with * below are REQUIRED.


1.
* Program applying for:
Incubator Accelerator

2.
* Company Name:

3.
* Principal Officer/Title:

4.
* Name of person completing this application:

Contact Information for Primary

5.
* Name:

6.
* Title:

7.
* Home Address:

8.
* City:

9.
* State:

10.
* Zip:

11.
* Primary Phone:

12.
Fax:

Company Information

13.
* Description of product/service:

14.
* Background of Officers:

15.
* Date established:

16.
* Company form:
S-Corp Sole Proprietor Other
C-Corp LLC

17.
* Status of Company:
Start-up Product Development
Prototype Full Operation

18.
* Current Sales Revenue:

19.
* Number of employees (FT/PT):

20.
* Financing to Date:
Personal Venture Capital
Private Investors Other

21.
* Plans for future rounds of financing:

22.
* Status of business plan:
Not started Partial Completed

23.
* Why company will be located in Tampa Bay region:

24.
* Space requirements: Square footage for - office, manufacturing:

25.
Special facility requirements (electrical, ventilation, floor load, etc.):

26.
* Desired date for occupation:

27.
Tax ID Number:

28.
North American Industrial Classification (NAICS):

29.
* Primary services requested:
Consulting Services Access to Capital
Telecommunications Facility Space
Strategic Partners/Alliances Other

30.
* Intellectual Property status:
Patent Pending Patent Exclusive License
Copyright Non-exclusive License Copyright Pending

31.
* Applicant hereby acknowledges that its application to and submission of information to the City of Clearwater does not guarantee admission into the incubator program nor does it create any rights in applicant to future consideration. The Review Committee retains full discretion as to admission into the Program and reserves the right to reject any applicant for any reason. Applicant hereby waives any right of appeal or legal action against any and all parties associated with the Incubator, including but not limited to Pinellas County, Pinellas County Industrial Development Authority, Pinellas County Economic Development Authority, and the City of Clearwater. All applications will be held in confidence and will be retained in the City's Economic Development Department's files unless otherwise requested in writing by applicant. Applicant agrees to indemnify, defend and hold harmless the City of Clearwater, its directors, officers, employees, operator, consultants and any governmental agencies associated with the Incubator from any and all claims, actions, causes of action, damages and liabilities asserted against the aforementioned individuals or entities arising out of or in any way connected with the activities and services provided by the Incubator, including, but not limited to, the provision of space, training or classes. Do you acknowledge that you have read and acknowledge the above disclaimer?
Yes

32.
* Enter Your Email Address:



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