Alliance for Technology Commercialization

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Alliance for Technology Commercialization, Inc.
Web Enabled Client Application

The information requested in this data sheet is to be used by ATC to help us further understand your business venture and determine ways in which ATC may be of assistance.

Company Information

Company Name:

Company Address:

Contact Person & Title:

Address:

Email:

Phone:

Fax:

Referred by:

Business Definition:
(Please briefly describe your business/idea in the space below)

Product/Service:

Industry and SIC Code:

Target Market (including market niche,size of market, potential penetration of market):

Development stage of your product:

Idea/Concept

Operational Prototype

Product Developed - No Sales Made To Date

Product Fully Developed - Sales Achieved

Financials:

Revenues in most recent fiscal year:

Revenue forecast for current year:

Revenue forecast for next 3 years:

First Projected Year:

Second Projected Year:

Third Projected Year:

Is your business incorporated?

Yes

State of incorporation:

Year:

Type (C, S, LLC):

Describe any relationship with larger or parent organizations:

Do you have a written business plan available?

Yes

In Progress

Intellectual Property Issues:

Patents

Granted

Applied

Plan to Apply

Copyrights

Granted

Applied

Plan to Apply

Trademarks

Granted

Applied

Plan to Apply

Area of intellectual property or proprietary technology:

Communications

Computer Related (hardware, software, graphics, services)

Medical/Health Care

Consumer ( products/services, franchise, retailing)

Distribution (computer, consumer, industrial, medical)

Aviation (composites, avionics, services, aerodynamics)

Other:

Do any other individuals or organizations own a share of the intellectual property? If so, please list and explain:

Financing/Investment Capital:

How much financing have you received to date? (specify equity and debt amounts):

Self:

Family/Friends:

Individual Investors:

Bank:

Venture Capitalist:

Other:

What are the terms of the financing? (equity %, debt repayment, royalty %):

How much capital is needed to fulfill your business plan?

Management:

Management Status:

Single Entrepreneur/Founder

Two Founders

Partly Staffed Management Team

Fully Staffed, Experienced Team

Current number of full-time and part-time employees?

Full-time

Part-time

Current number of board members?

List names of current board members:

Describe background of key management and entrepreneurial experience:

What business services does your company need?

Business plan preparation

Conducting market research

Conducting concept feasibility study

Financial/accounting assistance

Management team development

Intellectual Property Assistance (patent, copyright, or trademark search or application process)

Prototype development assistance

Marketing plan development

Manufacturing (process, facilities)

Strategic Partnering

Assistance in raising capital:
Equity	Debt	Grants

Other:

Submitted by:

Title:

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The Alliance for Technology Commercialization, Inc. was founded in 1997 through a joint effort of the Kansas Technology Enterprise Corporation (KTEC), the City of Pittsburg, Kansas and Pittsburg State University (PSU). ATC›s mission is to advance and commercialize promising new technology-based companies, primarily in Pittsburg and southeast Kansas, that can reach sales levels of $5-$10 million within five years. ATC receives an equity position in exchange for services which creates a real partnership with mutual incentives between ATC and the company.

Alliance for Technology Commercialization, Inc.
1501 S. Joplin St., Shirk Hall #207
Pittsburg, KS. 66762-7560