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Note: All information provided in this application and at the applicant
representatives’ meeting with the Incubator Selection and Review Committee will be kept strictly confidential. This application will not be reviewed unless all questions are answered fully.

 
Basic Information

 
Name of Business: *

Please provide the name of your business.
 
Business Address: *

Please provide the address for your business.
 
Phone Number: *

Please provide a telephone number for your business.
 
Fax Number:

If you have a fax number, please provide it below.
 
Website:

If your business has a website, please provide the address below.
 
Names of all principals and owners: *

Please provide the names of each of the principals and owners of your business.
 
Please attach resumes or c.v.s of principals and owners. *

Please upload a copy of your resume or c.v. below. You may upload one at a time. If you need to upload more than one, please use the subsequent upload boxes after this question.
 
Upload an additional resume:

 
Upload an additional resume:

 
Home and other business addresses of all principal(s) and owners (if different from business address above).

 
Please provide a concise description of your technology business enterprise and attach the executive summary of your business plan or a summary describing your (new or enhanced) technology, market, competitive advantage, financing plan, and how you expect to achieve your key business objectives in the first three years. Please enclose corporate or product brochures if available. *

 
Please provide a non-confidential description of your technology and its differentiating feature(s) in comparison with similar products/services. *

 
Business Profile

 
When and by whom was the company started? *

 
Please indicate your company’s current stage of development. *


 
Please describe the company’s management structure, including titles and descriptions of all management positions – how are the members of your company organized to perform its functions? What role does each of the principals or owners named on page 1 play in the company? Who will conduct the company’s programs within the campus incubator facility you wish to enter? Should this person be regarded as the contact for campus programs? *

 
Indicate your current number of employees, full time and part time, and the total number (current plus additional) you anticipate having in the foreseeable future (now, next year, and three years from now). *

 
Have you or any other principal or owner ever started a company before? *

     
 
What is its current status and your/the principal’s relationship to it? Please summarize what you learned from this experience. *

 
Financial Status:

 
Please provide your gross sales revenues from last year, if any: *

 
Please provide your net profit/loss from last year: *

 
Please provide an annotated list of your current sources of funding other than sales revenues. (e.g., investment capital [including principals and owners], Federal grants or contracts). *

 
Attach financial statement for most recent year or indicate current assets and liabilities below:

 
Have you ever filed for bankruptcy as either an individual or corporation? *

     
 
Please provide details: *

 
Please attach the executive summary of your marketing plan or provide a summary document describing: the market for your product or services [regional, national, international?] Include an assessment of the strengths and weaknesses of your competitors. How does the differentiating feature(s) of the product you named on page 2 constitute a competitive advantage, how have you ascertained the market demand for this advantage and how do you propose to maintain this advantage in the marketplace? *

 
Estimated amount of space needed (square feet) upon moving in, next year, and three years from now. Make sure to separate lab space from office space: *

 
Please indicate what Stony Brook University resources may be of interest to you: *


 
Because you chose the "other" option, please provide a description of your specific set of needs below: *

 
Please describe if you expect to use radioactive materials or hazardous materials (according to OSHA definition). Please note that while LIHTI is a private facility affiliated with Stony Brook University it does not enjoy any exemptions from federal, state, or local regulations. *

 
Unusual facilities needs, if any (please describe): *

 
Desired move in date: *

 
Anticipated graduation date: *

 
If you currently have a relationship or connection with Stony Brook University, please describe below: *

 
Please check the incubator facility or program which you are applying for: *


 
Because you selected "other" please describe what program you're applying for below: *

Note: If you are applying for campus space, you must provide documentation of approval by the responsible chair and dean, as well as SBU Procurement Office, before an agreement may be completed.
 
For your information: Selection Criteria

 
Please Note:

Selection criteria used in evaluating applications to the incubator program include:

Consistency of the ventures identified or planned industry or business sector with LIHTI's mission of supporting the future leaders of Long Island's high technology economy.

Demonstration of capacity to achieve the venture's business goals including expertise in chosen technology field(s), market assessment, management team, adequacy of financial support (including at least six months rent in a current account)

It is expected that applicants will submit executive summaries of their business plans as part of the application process, but lack of a business plan will not disqualify an applicant from consideration. However, if accepted, the venture must agree to work with the Small Business Development Center or obtain other appropriate expertise to prepare a business plan and must submit this plan at the first annual review.

Preference is given to applicants desiring to collaborate or interact with University facilities and staff, and demonstrating ability and willingness to participate in/benefit from University mission/activities, especially its economic development programs.

Note: Additional criteria may apply for some specific incubator programs.

To receive approval and complete an agreement for the licensing of space in one of these facilities, applicant must:

Demonstrate ability to pay rent for the first six months.

Agree to comply with all federal, state and local laws, licensing and permitting requirements, and all applicable campus policies. Failure to comply will trigger an immediate re-review of tenancy.

Agree to work with the NYS Small Business Development Center on the Stony Brook campus or another business advisory resource and provide a written business plan within 12 months of entering the incubation program.

Make efforts to interact with or utilize programs, facilities and/or technologies of Stony Brook University.
 
By agreeing to these terms, the applicant accepts and fulfills all of the above conditions and furthermore: *

1. Acknowledges reading and accepting the selection criteria.

2. Acknowledges agreement to abide by incubator policies described in any and all attachments to the lease or space licensing agreement.

3. Authorizes incubator to conduct a credit check of principals, owners and investors
     
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