Incubator Client Information Form
Date:
1/1/2017
This Survey has been deactivated
Lease Information:
Principal on Lease (Last, First):
Incubator Name:
Incubator Room Numbers:
Incubator Space (sq. ft.):
Current FTEs:
FTEs Anticipated in 12 Months:
Business Information:
Business Name:
Business Type:
Current Student Interns:
Current SUNY Graduate Employees:
Business Description:
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Technology Description:
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Income Statement:
Amount
2015 Total Revenue:
2015 Total Expenses:
2016 Total Revenue:
2016 Total Expenses:
2017 Total Revenue (Forecast):
2017 Total Expenses (Forecast):
Grants Awarded:
Amount
Source
2013 Grants:
2014 Grants:
2015 Grants:
2016 Grants:
2017 Grants:
2018 Grants:
Employee Hires
(to date)
:
Number
Positions
2013 FTEs:
2014 FTEs:
2015 FTEs:
2016 FTEs:
2017 FTEs (Forecast):
Projected Exit Date:
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Equity/Debt Raised:
Amount
Source
2013 Capital Raised:
2014 Capital Raised:
2015 Capital Raised:
2016 Capital Raised:
2017 Capital Raised (Forecast):
Use of University Facilities and Programs (Please check all that apply):
Attended University Workshops/Events
Collaberated with University Faculty
Accessed University Labs/Equipment
Hired University Students
Received SBDC Counseling
Mentored/Collaborated with Other Tenants
Worked with a CAT (Bio, Sensor, Other)
Met with Incubator Advocate
Completed SPIR Project
Negotiated with Licensing and Industry Relations
Top 4 Previous 12 Month Goals/Milestones Met:
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Top 4 Projected 12 Month Goals/ Milestones:
1)
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4)
Exit Strategy:
Comments: