Company You may use a placeholder name if you do not yet have an established company. Company Type You may use a placeholder if you do not yet have an established company. --None-- Not Incorporated LLC C-Corp S-Corp Other - specify Company Type - Other: State of Incorporation: --None-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other - Outside of US First Name Last Name Email Phone Street City State/Province Zip Country of Company Origin: --None-- United States Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Cotonou Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burma Burundi Cabo Verde Cambodia Cameroon Canada Central Africa Republic Chad Chile China Colombia Comoros Congo (Republic of Congo) Congo (Democratic Republic of Congo) Costa Rica Côte d’Ivoire Croatia Cuba Cyprus Czechia Denmark Djibouti Dominica Republic Dominican Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Republic of Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Holy See Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Namibia Nauru Nepal Netherlands The Hague New Zealand Nicaragua Niger Nigeria North Macedonia Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Vincent and the Grenadines Saint Kitts and Nevis Saint Lucia Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Sweden Switzerland Syria Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Kingdom United Arab Emirates Uruguay Uzbekistan Vanuatu Venezuela Vietnam Yemen Zambia Zimbabwe Please introduce your venture, the problem you are solving and your proposed solution: Who are your customers and/or users and what stage of customer discovery you are in? What is the unique value proposition you plan to provide to your customers? What is your business model? How do you plan to make money? Briefly list the team members. List each team member’s significant contribution/s to the venture: Briefly describe where funding currently comes from and your funding plans for the next 24 months: What is the current status of the product/service you provide? Idea Stage Prototype Customer-Ready In the Market What services do you hope to obtain from the University of Arizona Center for Innovation? Mentorship Offices Access to Labs Investment Support Connections to Community Support Connections to the University of Arizona Connections to Other Startup Entrepreneurs Please indicate if you have any connection to the University of Arizona. This is not required for participating in this program but for informational purposes only. Negotiating a License Agreement License Agreement UA Student UA Alumni Other No UA Connection What steps have you taken – or do you intend to take – to protect the intellectual property embodied in the innovation? What milestones does the team intend to complete during the next 6-12 months? What do you feel are the biggest challenges facing your venture? Market Validation Developing Business Model Expanding Team Fundraising Technology Development Securing Intellectual Property Operations Facilities