Application:

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Application for Occupancy at the
Innovation Center @ Wilkes-Barre

To officially apply to the Innovation Center @ Wilkes-Barre you will need to submit: 1) a completed application form, 2) a copy of your business plan, including three-year financial projections and 3) a copy of each shareholder's most recent tax return (or a business tax return if the business has already been in existence for at least one year).

BASIC CONTACT INFORMATION:

Name: ____________________________ Date: _______________
Name of Business: _____________________ Website: _________________________
Phone: _____________ Fax: _____________ Email: ___________________________
Address: _______________________________________________________________
Social Security Number: _________________________

Partner(s)/Principal(s) Name: 1. _________________________ Phone: _____________ SS#_______________________ % ownership: __________

2. _________________________ Phone: _______________
SS#_______________________
% ownership: _________

3. _________________________ Phone: _______________

SS# _______________________ % ownership: __________

4. _________________________ Phone: _______________
SS#_______________________ % ownership: __________

Attorney Name: ________________________________ Phone: _______________
Accountant Name: ________________________________ Phone: _______________
Bank Name: ________________________________ Phone: _______________

SPACE REQUIREMENTS

Square Footage you are interested in: _________ Desired Date of Occupancy: ___________ Electric Type of Equipment __________________ #volts ______ #amps______
Phase Type of Equipment __________________ #volts ______ #amps ______
Phase Special Lighting Needs?___________________________________________________
Telecommunications Own System? ________ # Lines Voice: ________ # Lines Fax: ______
# Computers to be connected to Innovation Center Network: __________

Other Special Needs?_________________________________________________________

BUSINESS INFORMATION

New Business: __________ Existing Business:__________ Year Established:_______
Where was the Business Started: _________________ # of Employees: Full____ Part_____
Legal Structure of Business: ____Sole Proprietorship ____Partnership ____Corporation
Please Describe the Business: ____Idea Stage ____Early Stage ____Prototype Stage - (manufactured & sold in small quantities) ____Developmental Stage - (product maturity, sales volume & management capability) ____Expansion Stage - (capable of standing on your own) Briefly describe your business, product, service and associated technology: _______________________________________________________________________

Describe your business background or experience with product/service: _______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

How is your business, product, service unique? _______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Briefly describe your target market and market size: _______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Can your business/product/service or technology be patented, trademarked or protected from duplication? _____Yes _____No

Estimated Employment: Direct/Indirect at time of occupancy: Full Time____ Part Time____ _______ One year later: Full Time____ Part Time____ _______

Within 3-5 years: Full Time____ Part Time____ _______

Please list the type of services/assistance your company will require: _______________________________________________________________________

_______________________________________________________________________

FINANCIAL INFORMATION

What is (will be) the primary sources of financing for your business? _______________________________________________________________________

_______________________________________________________________________

Current capitalization of your business? ____$0-$50,000 ____$50,000-$100,000
____ $100,000-$150,000 ____Over $150,000

Additional near-term contemplated capitalization?______________________________________ Total assets:_________

Total revenue past 12 months:________ Annual growth rate-%:_______ Are you willing to accept and act upon advice from a board of mentors appointed for you? _____Yes _____No Are you willing to have your financials and business plan reviewed by the board twice a year? _____Yes _____No

How did you hear about us? _______________________________________________________________________

Additional comments: _______________________________________________________________________ ________________________________________________________________________

NOTE: In order to be considered for the incubator program and to expedite the process, please include the following: 1) completed application form 2) copy of your business plan, including three-year financial projections 3) copy of each shareholder's most recent tax return (or a business tax return if the business has already been in existence for at least one year) 4) any other pertinent information, e.g. annual report, brochure. Should you have any questions or comments or require any help, please do not hesitate to contact the Innovation Center @ Wilkes-Barre Director, John L. Augustine III at 570-823-2101 or email at info@icwb.biz. Please send all items to: Innovation Center @ Wilkes-Barre, Two Public Square, P.O. Box 5340, Wilkes-Barre, PA 18710-5340. I verify that this information is current and accurate and that it may be confirmed.

Signature:_______________________________ Date: _________________

This document is confidential. It is not for re-distribution. This application may contain ideas, inventions, proprietary information and concepts (collectively, "Ideas") and all parties involved agree that they will not copy, reveal, or disclose such Plans, Ideas or Proprietary Information to others, and that they will not use any such Plans, Ideas or Proprietary Information for their own benefit or for the benefit of any person or entity with which they are affiliated.