Research & Innovation » USF Research Foundation, Inc. » TBTI

Application / Client Review Form

Please review the Tampa Bay Technology Incubator Admissions Process and Tampa Bay Technology Incubator Selection & Eligibility Criteria carefully before completing the application below.

Date:
Company Name:
Address:
City, State, Zip:
Website:
Contact Name:
Title:
Phone Number:	( )
Fax Number:	( )
Email Address:
Industry:
Company Description:
Principle Product/Service:
Management Team: (CEO, CFO, CMO, CSO, etc.)
Any Expected Changes to management in next 6 months?
Current Investors: How Many? Who?
Funding to Date:
Financing Sought:
Use of Proceeds:
When and where was the company founded?
Current Business Model:
Competition:
How can the Tampa Bay Incubator assist the company in achieving its 6 month goals/milestones?
Law Firm(s):
Bank:
Accounting Firm:
Who comprises the Board of Directors and are there any expected changes in the next 6 months?
Has the company approached any angels and/or VC's in last 6 months? Plans to approach any within the next 6 months? If so, whom, and what was the outcome of any previous discussions with these firms?
Current Target Markets:
Milestones/Intellectual Property Status:

	Current	Next 6 months	+6 months	+6 months	+6 months
Date
Total Employees
Number FTE
Average Salary
Total Funding (excluding sales revenues)
Amount Received in last 6 months
Expected Funding within next 6 months
From who/what expected sources?
Annual Revenues
Annual Expenses
Cash Requirements
Monthly Burn Rate

Please provide TBTI with intent of use of the programs/services listed below.
Please rank the program/service 1-5, 5 being the highest. If the company does not plan to use the program or service, please select N/A.

Program/Service	Frequently Attended/Used	Ranking
Brown Bags / Seminars
Boot Camps / Entrepreneurial Trainings
Hillsborough County SBIC Counseling
FHTC Matching Grants Research Program
Research Park Parking
USF CONNECT provided Internet
Access to Facilities
USF CONNECT Meeting Facilities
USF CONNECT Hours of Operation
USF CONNECT Resource Center
USF CONNECT Publicity
Shared Lab Facilities
NMR (Nuclear Magnetic Resonance)
FTIR Spectrometer
UV/Vis Spectrophotometer
DSC (Differential Scanning Calorimeter)
HPLC (High Performance Liquid Chromatography)

Please enter the code as it appears in the image below:

Office Location:
USF Research Foundation, Inc.
3802 Spectrum Boulevard, Suite 100
Tampa, Florida 33612-9220

Campus mailpoint:
30338 USF Holly Dr.

Telephone: (813) 974-1082

Fax: (813) 396-9313

Paul R. Sanberg, Ph.D., D.Sc.
President, USF Research Foundation