Insight Park Application
Please complete the form below and we will evaluate it and get in touch with you as soon as possible.

Company Name *
Title *
Email Address *
Contact Person *
Contact Person *
Phone Number *
Work Address *
City *
State *
Zipcode/Postcode *
Country *
Has the company been incorporated? *
If your company is already incorporated, please enter the date it was incorporated (MMDDYYYY)
State of incorporation *
What is the legal form of your business? *
Number of employees today *
Please estimate the number of employees in 3 years *
Does the company have a business plan? *
Briefly describe your business. What market need are you solving? What is the solution you are offering? Who are your target customers? *
Do you hold proprietary rights (patents/licenses) for the technology you are developing? *
What will your monthly operating expense be for the first twelve months? (Include items such as rent, wages, inventory, phones, marketing, etc.) *
How will you fund your operation for the next 12 months? (i.e. cash reserves, credit cards, investment, operating revenue, bank loan, grant, etc) *
Have you secured any of the following to capitalize your business? *
Approximately how much space, in square feet, will you need? *
What type of space do you need? *
When do you anticipate you will need to occupy Insight Park space? *
Will you be connecting any servers to the campus network from space in Insight Park? If yes, how many and for what purpose? *
Will you be offering any Internet-based information services to consumers for a fee using systems hosted at Insight Park? If yes, please describe. *
Do you anticipate needing to transfer very large amounts of data using network services provided by Insight Park? If yes, please describe. *
If you will be conducting research that requires the use of any chemicals, please list them below. MSDS for each must be provided to Insight Park if your company is accepted. *
Please indicate what information/service connections you may request from the incubator. *
Required
Please indicate if you have any of the following service providers. *
Required
Are you interested in utilizing co-op students or student interns? *
If so, in what capacity?
If you have an existing relationship with a research at the University of Mississippi, please describe that relation and the activities taking place.
My submission of this form certifies that all the information contained herein is true and complete. *
Required
Submit
Never submit passwords through Google Forms.
This form was created inside of University of Mississippi. Report Abuse