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First Name

Last Name

Company Name

Company Website

Email

Phone Number

Indiana County Adams County Allen County Bartholomew County Benton County Blackford County Boone County Brown County Carroll County Cass County Clark County Clay County Clinton County Crawford County Daviess County Dearborn County Decatur County DeKalb County Delaware County Dubois County Elkhart County Fayette County Floyd County Fountain County Franklin County Fulton County Gibson County Grant County Greene County Hamilton County Hancock County Harrison County Hendricks County Henry County Howard County Huntington County Jackson County Jasper County Jay County Jefferson County Jennings County Johnson County Knox County Kosciusko County LaGrange County Lake County LaPorte County Lawrence County Madison County Marion County Marshall County Martin County Miami County Monroe County Montgomery County Morgan County Newton County Noble County Ohio County Orange County Owen County Parke County Perry County Pike County Porter County Posey County Pulaski County Putnam County Randolph County Ripley County Rush County Scott County Shelby County Spencer County St. Joseph County Starke County Steuben County Sullivan County Switzerland County Tippecanoe County Tipton County Union County Vanderburgh County Vermillion County Vigo County Wabash County Warren County Warrick County Washington County Wayne County Wells County White County Whitley County Out of State International

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 Native Asian American Indian Asian American or Pacific Islander (non Hawaiian) Latino or Hispanic Middle Eastern Native Hawaiian White, Caucasian (Non Hispanic) Woman Non-binary or non-conforming Lesbian Gay Transgender Bisexual Justice-Involved Military Veteran Neurodiverse Person with a Disability Prefer 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

Are you an IU LAB startup Yes No

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