EOY Application

Entrepreneur of the Year Application

If you need any help with the application, call the Alliance at 603-935-8951
Submission and materials deadline is Friday, May 3, 2019
APPLICANT INFORMATION
Name*

First NameLast Name
Email*
example@example.com
Phone*

Area CodePhone Number
Business Name*
Job Title*
Business Address*

Street Address

Street Address

CityState

Zip Code
Co-applicant names (if any)
Previous awards or industry recognition, if any
Education (degrees, years, honors, etc.)

FINANCIAL DATA

The Judges weight revenue and employment growth heavily in their evaluation. Profitability or other demonstration of value creation is also a key consideration. Please provide as much detail as possible.
Has the company merged with, acquired, or been acquired by another company within the last three years?*

YesNo
If yes, what year?
If yes to previous question, what % of growth reflected in the financial data below is attributable to the merger/acquisition?
%

	Most recent year-end	2nd most recent year-end	3rd most recent year-end
Ficscal year-end date
Number of employees
Net annual sales
EBITDA
Total assets
Net owner's equity

In 250 words or less, describe the Applicant’s entrepreneurial background including special skills, experience, major accomplishments, etc. List business, community, or civic organizations of which the Applicant is a member and the extent of his/her involvement. Active community participation is important in the overall evaluation process.

0/250
In 250 words or less, describe the history of the Applicant’s company (or organization). Include the source of the idea for the original business strategy, the financial risk involved and any other pertinent information. It is important to delineate the use of innovative approaches, management and marketing. Also, provide specific information about the company’s current stage of development and future prospects.

0/250
In 250 words or less, describe how the Applicant’s company (or organization) is unique or innovative in its relations with (a) its employees and (b) its customers. Also, briefly describe the major products and/or services. Include the reasons the Applicant’s company (or organization) is unique and/or has demonstrated excellence in its field.

0/250
Attach promotional material about the company (or organization).

Upload File(s)

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In 250 words or less, describe the Applicant’s plans for the future of the company (or organization) which demonstrates the Applicant’s innovative planning skills.

0/250
In 250 words or less, describe any other considerations that demonstrate the Applicant’s skills, experience, etc., including the selection of the key management team members (other than the Applicant), and detailing the Applicant’s experience, special skills, and major accomplishments. Provide specific examples of management or business successes.

0/250

EXTERNAL ADVISORS AND REFERENCES

Please list below the individuals who have assisted the Applicant in his or her entrepreneurial efforts, and who may serve as references.

Representatives of the NHTA EOY Committee may contact these advisors and references to verify information and gain a deeper insight into the Applicant.
BANKER
Bank
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ATTORNEY
Firm
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
FINANCIAL ADVISOR
Firm
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional reference letters (no more than two) may be submitted as well, but are not required.

Upload File(s)

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OTHER INFORMATION
Have you previously submitted an application for consideration?*

YesNo
Where did you learn about the NHTA Entrepreneur of the Year Awards Program?

CERTIFICATION
To the best of my knowledge, the information provided herein is true and complete.

ALL FINANCIAL INFORMATION CONTAINED HEREIN SHALL REMAIN CONFIDENTIAL UNLESS I AGREE TO ITS RELEASE.

If I am selected for a NHTA Entrepreneur of the Year Award, I hereby authorize, in connection with the NHTA Entrepreneur of the Year Program and/or the NH Tech Alliance, the use of my name, my company’s name, non-financial information, likeness, photographs, video recordings, and audio recordings of me from whatever source. I agree that no compensation shall be due me or my company for such usage.

I understand that an interview will be conducted by a representative of the NHTA EOY Committee.

I also understand that if I am selected for the 2019 NHTA Entrepreneur of the Year Award, I will be required to attend the Awards Gala to receive my award. The event will be held on June 13.
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
Secure submission*
Should be Empty:

Entrepreneur of the Year Application