Launch // Intake Form

Client Intake Form

To be considered for Launch services, we ask that you complete the following questionnaire.

All information is stored in a secure database and available only to Regional Growth Partnership staff.
Your submitted information is highly confidential and not shared beyond our staff without your knowledge.

If you're not sure how to answer required fields, please make a best guess. More accurate or appropriate answers can be resolved with follow-up visits.
Required fields are marked *.

Company Contact
Your Title:
Your Full Name:
Your Position With The Company:
Phone:
Cell Phone:
Email Address:	(E-mail)
Company Information
Company Name:
Address:
Address 2:
City:
State:
Zip Code:
FAX Number:
Website Address:
About My Company
Which Technology Area Do You Best Fit?:
What Best Describes The (Stage of Development) of Your Product/Service?:
Do You Possess Intellectual Property?:	Yes No
If Yes, Please List Patent Numbers, Titles, Trademarks, Copyright Registration Numbers:
Company Mission Statement:
What Is Your Product?:
What Problem Does Yor Product/Service Solve In The Market Place?:
Additional Comments:
Company Dollar Status
Number Full Time Employees:
Revenue Total For The Last 12 Months?:
Capital Investment To Date:
Have You Received Other Investment Funding?:	Yes No
If Yes, Pleease Describe That Funding:
How Did You Hear About The Launch Program?:
Has There Been Previous Contact With Launch?:	Yes No
Do You Have A Business Plan?:	Yes No
Upload Your Business Plan (Optional):	To Upload - Your Business Plan file must be a PDF, 5 megs or less.

Company Contact

Company Information

About My Company

Company Dollar Status

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