Partner Company Application
This form is used to properly assign your company to the appropriate clinician.
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Company Name *
Year of Formation *
Point of Contact (First Name) *
(Last Name) *
Email Address *
Company Website *
Physical Address *
Description of Problems/Issues to be addressed by the Clinic *
Priority *
Estimated Time needed to complete *
In what Industry does your company compete? *
Form of Legal Entity *
How have you funded the company thus far? *
Required
Have you generated revenue at this point? *
How many employees are working within the company? *
Do you have an advisory board? *
Do you have a mentor/advisor that you rely on for feedback? *
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