Condensed Version MBA Web Intake Form

Minority Business Accelerator

Intake Application for Potential Investments & Portfolio Companies
- Name
  
  First NameLast Name
- Email
  example@example.com
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Are you the majority shareholder/owner of the business?
- Business Name
- Business Establishment Date
- Company Description
  Describe the product or service that your business provides in 1-2 sentences.
- Headquarters/Office Address
  Street Address Address Line 2 City State Zip
- Industry Sector
  
  Other
- Company's Legal Structure
- MBE Ownership
- MBE Certified
- WBE Certified
- List MBE and/or WBE Certification(s)
  List all MBE and/or WBE Certification(s) currently active
- The Business has sustained sales of $1M in Annualized Revenue
- The Business is a B2B and/or B2G solution
- Major Clients:
- 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)
  
  Other
- Management is receptive to new ideas and strategies by external parties
- Check MBA services you are interested in learning more about:
- 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
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- 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
- Should be Empty:

Minority Business Accelerator