Basic Information

Entrepreneur Marital Status:

SingleMarriedDivorcedOther

Company Profile

Company Summary:

Company Entity Registration Type:

LLCFree ZonePartnershipSole TraderNot Registered / Other

What stage is your company's primary product or service offering?

ConceptDevelopmentTesting (Alpha or Beta)LaunchedEstablished (Revenue Generating)

Is there currently a female in an executive C-suite position within your company?

YesNo

If not, do you intend to engage a female in an executive position?

Ownership of Company by percentage: (Click + to add additional owners)

Management team: (Click + to add additional members)

What type of experience do you have? (Select up to two)

Industry experienceEntrepreneurial experienceExperience with liquidity and exitExperience building a companyNo directly relevant experience

How will your management teams experience and qualifications assist in your success?

Upload Management Team CVs

NB: PDF or Word Document only - max file size 3MB

Does anyone in your team have any restrictive covenants attached to them or any intellectual property agreements that would conflict or restrict your business?

Number of employees

0-55-1010-2030-5050+

How many hours per week are you prepared / available to commit to your business?

≤ 1011-2021-4041-5051+

Company Social Media Presence – Please add links to any:

LinkedInTwitterFacebookInstagramNone

Market Opportunity

How large do you anticipate your target market to be?

< $10 million$10 – $100 million$100 – $500 million$500 million - $1 billion> $1 billion

Describe your target market:

What is the annual growth rate of your target market?

< 0%0-10%10-20%> 20%

Explain your reasons for bringing your product or service to market?

Explain how your product or service will solve the customer problem:

List your current or potential customers:

How many paying customers does your company currently have?

01-33-1010-2020-50> 50

What is your business model e.g. the strategy will you employ to build, deliver, and retain company value (e.g., profits)?

What is your company's competitive advantage?

Describe your barriers to entry:

Do you have a lead on your competitors? If so how much?

12 month lead6-12 month lead3-6 month lead0-3 month leadWe are behind our competitors

List your competitors:

What is your customer acquisition and retention strategy?

Funding & Financials

What do you currently value your business at? (US$)

How much of your own funds have you invested in your business to date? (US$)

How much of your own funds are you prepared to additionally invest in your business? (US$)

How much external capital has your business raised to date?

None$1-$50,000$50,000-$100,000$100,000-$500,000$500,000-$1 million$1-$5 million> $5 million

How much equity capital are you seeking?

None$1-$50,000$50,000-$100,000$100,000-$500,000$500,000-$1 million$1-$5 million> $5 million

Estimated value of your business? (US$)

Monthly Burn rate (current amount of money spent per month): (US$)

Current average monthly sales revenue: (US$)

When will your company make profit?

Profitable now< 1 year1-3 years3-5 years> 5 years

Actual and Projected financial information

Upload any audited financial statements for the last 3 years and current year management account, if available

NB: PDF or Word Document only - max file size 10MB

Describe your Exit Strategy

IPOAcquisitionNo intention to exitI do not know

What are you looking for in an investor?

FundingMentoringNetworkingOperational and management support

How much share capital are you willing to give up?

None0-15 %15-30 %30-50 %>50 %

Are you prepared to give an investor partial control of your company and a seat on the Board?

YesNoI do not know

How do you plan to use the funds should you receive them?

Key Documents

Please attach any other information you believe relevant to your application including business plan, pitch video, press release etc.

NB: PDF or Word Document only - max file size 10MB

Link to pitch video: (URL)

Declaration

I declare that the information I have given on this application form and any supplementary pages is correct and complete to the best of my knowledge and belief.

I have read and accept the Terms of Use and Privacy Policy.

Disclaimer: Notwithstanding any language to the contrary, nothing contained in or through this application form constitutes, nor is intended to constitute, an offer, inducement, promise, or contract of any kind.