Proofing Station

Contact Name

Contact E-Mail

Contact Phone

Referral source (please list the person and/or the organization)

State in which the organization is headquartered

State(s) in which the organization operates

Brief description of organization

Annual revenue

Is the organization a for profit or non-profit

Which gender best describes the majority of the company founding / management team?

Which race or ethnicity best describes the majority of the company founding / management team?

What kind of support is the organization seeking?

What is the amount of total financing or total financial support you are seeking?

What will you use the financing for?

If other, please describe:

What is the size of your full time staff?

What is the size of your part time staff (including consulting and seasonal)?

Have you received any state or Federal funding before?

If you answered yes to the funding question above, what kind of funding?

If other, please describe:

Intake Form