MBA Fund 1 Web Intake Form vF

Minority Business Accelerator Fund 1

Intake Application for Potential Investments

Contact Information
Name

First Name Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Are you the majority shareholder/owner of the business?

YES NO

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

Technology Data Analytics Fin-Tech Construction Distribution Energy Financial Services Manufacturing Professional Services Transportation Real Estate HR Services Other
Company's Legal Structure

Organizational Structure

	Name of Leadership Team	Years in the Role
CEO/President
COO/General Manager
CFO or CPA
Marketing & Sales Leader
HR Manager
Others

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 American Hispanic Native American/Indigenous None
MBE Certified

Yes No
WBE Certified

Yes No
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

Yes No
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

	Bank Name	Credit Type	Amount	Total AMT
Note 1
Note 2
Note 3
Note 4
Note 5
Total

Customer Information
The Business is a B2B and/or B2G solution

Yes No
Major Corporate Clients:
Major Gov't/Public Clients:

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 Capital Marketing Hiring/Recruiting Asset Purchase Inventory Business Acquisition Relocating Other
Do you already have investors in your business?

Final Steps
Business Overview Documentation

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

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P&L / Balance Sheet / Cash Flow Model / Cap-Table / Exit Model / Investment Runway Estimation / Debt Summary / Business Model
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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.
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Minority Business Accelerator Fund 1