Contact Information. General Information: Company/Team Name: Company Website: (if available) Physical Address: City:

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1 Contact Information General Information: Company/Team Name: Company Website: (if available) City: State: Zip: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida additional choices hidden... South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Primary Contact Primary Contact: Address: Phone Number: Secondary Contact Secondary Contact: Address: Phone Number: Twitter Handle Facebook Page

2 How did you hear about Alabama Launchpad? Word of Mouth News article from Alabama Launchpad Social Media Online Ad Company Information Current Number of full-time employees: Current Number of part-time employees: Is the company incorporated? Yes What best describes the company s current location? Business Incubator Office Building Private Residence Inside University Virtual Accountant, and associated firm If applicable: Lawyer, and associated firm If applicable: Industry Category: (Please pick the category that best fits your startup) Biotechnology Business Services Products Clean Technology Computers Peripherals Consumer Products Services Education Electronics Instrumentation Energy Financial Services Food Drink... 5 additional choices hidden... Media Entertainment Medical Devices Equipment

3 Mobile Nanotechnology Other Retailing Distribution Semiconductors Software Telecommunications Travel Company Stage: Concept Only Proof of Concept Tested Proof of Concept Achieved Prototype Development Prototype Ready Less than $250,000 in Revenue $250,000 to $500,000 in Revenue $500,000 to $1 Million in Revenue Over $1 Million in Revenue Company Information Small Business Set-Asides/Designation a. Minority Business Enterprise b. Woman-Owned Business c. Veteran-Owned Business d. Disabled Veteran Owned Business e. Small/Disadvantaged Business SBA 8(a) Program f. Historically Under-Utilized Business (HUB) Zone Located g. Small Business h. ne Legal Structure (Current or Planned) a. C Corp b. S Corp c. Partnership d. LLC e. Sole Proprietor / Individuals f. Other Date of Formation (if applicable) Tax ID # (if applicable) University Affiliation (Alabama Public Research Institutions)

4 t applicable University of Alabama University of Alabama at Birmingham University of Alabama in Huntsville Auburn University Alabama State University Alabama A University University of South Alabama Tuskegee University If you have a university affiliation, have you met with your technology transfer office concerning this startup idea? (If not, please understand that if you are using university technology, you must meet with your OTT.) Yes t Applicable Status of University License N/A Agreement in place Under negotiation Name of OTT contact familiar with your license and/or technology If you have a university affiliation please provide additional details regarding meeting with technology transfer office. 210 characters max. Intellectual Property Please identify which type of intellectual property your business uses or relies on to support its business plan: (if any) Intellectual Property Copyright/Trademark Pending Patent Pending Copyright/Trademark Trade Secret Exclusive License Trade Secret Patent nexclusive license Proprietary Know-how Patent Status (if applicable) N/A Patent Pending (filing date) Patent Issued (issue date) Can you produce an ownership document (assignment, option agreement, license agreement) verifying that your company owns or controls the intellectual property described above?

5 Yes Please describe the ownership documentation you can provide. 440 characters max. Consent By checking this box, I understand that I may be required to prove by the end of the competition cycle, that I either have the rights or can negotiate for the rights to all intellectual property used.