First Name

Last Name

Company Name

Email

Phone Number

Ethnicity - will only be used anonymously for grant tracking purposes African American, Black (non-hispanic) Alaska Native Asian American Indian Asian American or Pacific Islander (non Hawaiian) I prefer not to answer Latino or Hispanic Middle Eastern Native Hawaiian Multi-ethnic/Multi-racial Other - I identify as a person of color Other - I do not identify as a person of color White, Caucasian (Non Hispanic)

What industry best classifies your business? Agbiosciences (plant & animal) Advanced Manufacturing & Logistics Life Sciences (human health) Technology My Industry is not listed

Product development stage Pre-Product Pre-Market Development Post-Market Update Expansion

Revenue stage Pre-Revenue Early Revenue (less than $1M) Growth Revenue (more than $1M) Expansion Revenue ($10M+)

Does your company's founder or CEO include the following? (select all that apply) African American, Black (non-hispanic)Alaska Native Alaska NativeAsianAmerican IndianAsian American or Pacific Islander (non Hawaiian)Latino or HispanicMiddle EasternNative HawaiianWhite, Caucasian (Non Hispanic)WomanNon-binary or non-conformingLesbianGayTransgenderBisexualJustice-InvolvedMilitary VeteranNeurodiversePerson with a DisabilityPrefer to not answer

Does your Does your company's Full-time Management include the following?(select all that apply) FemaleNon-binary or non-conformingMiddle EasternNative Hawaiian or Other Pacific IslanderJustice-InvolvedMilitary VeteranNeurodiverseDisabledHispanic or LatinoBlack or African AmericanAsianAmerican Indian or Alaskan NativeTransgenderBisexualGayLesbian

Have you participated in any accelerator programs? If so, please select any that apply. Techstars Sports (Indiana) Heritage Group Accelerator gBeta (any program) Be Nimble Other

What TechPoint programs are you interested in? Venture Support - Pitch Deck ReviewConnect to Industry Leaders through MentorshipVenture Connect EventsVCI Marketplace

Comments