MBA Fund 1 Web Intake Form vF

Minority Business Accelerator Fund 1

Intake Application for Potential Investments

Business Information (Investment or Acquiring Company)
Business Name
Business Establishment Date
Company Description
Describe the product or service that your business provides in 1-2 sentences.
Business Location
Street Address Address Line 2 City State Zip
Headquarters/Office Address
Street Address Address Line 2 City State Zip
Industry Sector

TechnologyData AnalyticsFin-TechConstructionDistributionEnergyFinancial ServicesManufacturingProfessional ServicesTransportationReal EstateHR ServicesOther
Company's Legal Structure

Organizational Structure

Number of Part-Time Employees blanks
Number of Full-Time Employees blanks
Number of Minority Employees blanks
Number of Female Employees blank
Employee Retention Rate
As a Percentage
Potential employment level in the next 12 to 24 months?
MBE Ownership

African AmericanHispanicNative American/IndigenousNone
MBE Certified

YesNo
WBE Certified

YesNo
List MBE and/or WBE Certification(s)
List all MBE and/or WBE Certification(s) currently active

Financial Information
The Business has sustained sales of $1M in Annualized Revenue

YesNo
Financial Screenshot - Revenue
Year 1 YTD Year 2 Proj. Year 3 Proj. Year 4 Proj. Year 5 Proj.
Financial Screenshot - Net Profit
Year 1 YTD Year 2 Proj. Year 3 Proj. Year 4 Proj. Year 5 Proj.
Financial Screenshot - Cash Flow
Year 1 YTD Year 2 Proj. Year 3 Proj. Year 4 Proj. Year 5 Proj.

Debt Outstanding

Fundraising Ask
How much funding are you seeking for your business?
If no funding is needed state N/A in the textbox
What is the proposed use (or uses) of these funds? (select all that apply)

Working CapitalMarketingHiring/RecruitingAsset PurchaseInventoryBusiness AcquisitionRelocatingOther
Do you already have investors in your business?

Final Steps
Business Overview Documentation

Business Plan, Marketing Deck, Executive Summary, LOI etc.
Cancelof
Financial Information

P&L / Balance Sheet / Cash Flow Model / Cap-Table / Exit Model / Investment Runway Estimation / Debt Summary / Business Model
Cancelof
Anything else we should know?
Confidentiality Agreement: Information will be held in strict confidence and shall not be used by the MBA and/ or the Cincinnati Chamber in any manner other than for the purpose for which it is intended.
Signature

Clear
Should be Empty:

Minority Business Accelerator Fund 1