MBI - Benefits

Membership Application

Thanks for considering Application to the MBI, you have two options:

Right click here: Download and "Save Target As" to your desktop. After filling the form out click file and send mail to dstolt@mtbiz.org

Fill out the PDF, print it and mail or fax it.

Fill out the following form and submit it.

Interview Questionnaire

1. Name (President or CEO):

Last:

Company Name:

Address: City:

State: Zip:

Phone: Fax:

E-Mail:

2. How is your Business organized?

Sole Proprietorship

Partnership

LLC

Corporation Type?

3. If this is an existing Business:

A. Date Business Started:

B. Where Started:

C. Stage of Development?

Stage

Early Stage

Prototype Stage

Developmental Stage

Expansion Stage

D. Number of Employees? Full Time: Part Time:

E. Do You Have An Existing Written Business Plan? Yes No

4. List The Names And Telephone Numbers Of The Business Principal(s):

_____ Name: TITLE: PHONE:

Name: TITLE: PHONE:

Name: TITLE: PHONE:

Name: TITLE: PHONE:

5. B. Type Of Technology Based Service Or Product Business:
:

Software

Computer Hardware

Peripheral Hardware

Telecommunications

Internet Or Web-Based Product or Service

Other

6. 4. Briefly Describe Your Business:

5. Briefly Describe Your Product Or Service:

8. 6. Describe Your Business Background Or Experience With Product/Service:

7. How Is Your Product / Service Unique?

10. 8. Describe Your Target Market And Market Size:

9. How Can Your Product or Technology Be Protected?

Patent

Trademark

License

Trade Secret

Other

10. What Is The Primary Source Of Funding For Your Business?

Savings

Operating Income

Equity Investment

Informal/Private

Venture Capital

Debt

Personal

Bank

11. How Will You Repay Investors?

12. Current Capitalization Of Your Business?

$O - $5O,OOO

$5O,OOO - $1OO,OOO

$1OO,OOO - $15O,OOO

Over $150,000

13. Additional Near-Term Expected Capitalization?

14. Total Business Assets:

17. Total Revenue (Past 12 Months):

18. Annual Growth Rate(%):

15. Estimated Employment:		I
Current?	Full Time	Part Time
One Year Later?	Full Time	Part Time
Within 5 Years?	Full Time	Part Time
	Direct	Indirect (Sub-contractors)

20. 16. What Do You Consider As Your Weaknesses?

21.

17. Are You Willing To Accept And Act Upon Advice From A Council Of Advisors Appointed

For You?

Yes No

18. MBI Service Requested:

Resident (Would Like To Move Into The MBI Facility)

Affiliate (Non-Resident Use Of Services Only)

24. 19. Describe What You Expect The MBI To Provide:

20. For Incubator Residents, What Is The Amount Of Space Needed? SQ. FT.

21. How Long Do You Expect To Be In The MBI Program?

27. 22. How Did You Hear About Us?

This form represents only a "Pre-Application" and not a formal commitment to become a client of the MBI program, nor does it represent a commitment of services by the MBI.