Small Company Innovation Program
Technology and Commercialization Assistance
APPLICATION
I. Firm Information
DATE: Click here to enter today’s date.
Firm’s Legal Name
Firm’s EIN
REFERRAL SOURCE: Choose a referral source
If Other Define: Referral name
FIRM’S PRIMARY PRODUCT(S):
DATE FIRM WAS CREATED: Click here to enter a date.
[Company Address]
City, State, ZIP
County
List primary products / technologies
NAICS: NAICS codes here
Fiscal Year Revenue (Projected): In Millions
FIRM’S TARGET MARKET(S):
List primary target markets
Current Employee Count:
FTE
Prior Fiscal Year Revenue: In Millions
Projected Employee Counts in (1 year; 2 years):
WEBSITE: Firm’s Website
PTE
Click here
II. Contact Information:
Contact Person
Click here to enter text.
Role Click here to enter text.
Phone Number
Click here to enter text.
Email Click here to enter text.
Related Companies: Click here to enter text.
Parent Company
☐
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Subsidiary
Other
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III. Ownership:
( At t a c h s h e e t i f n e c e s s a r y )
☐ LLC ☐ PARTNERSHIP ☐ S Corp ☐ C Corp ☐ SOLE PROP ☐ NOT-FOR-PROFIT ☐ L3C
Full Name
% Ownership
Full Name
% Ownership
IV. Michigan Operations:
Does this firm plan on remaining in Michigan?
YES ☐
NO ☐
Does this firm plan on improving the performance of its Michigan operations?
YES ☐
NO ☐
V. Resources Identification at
MCRN U n ivers it ies
What type of SCIP/TCA assistance does your company seek?
and other Mich ig an ’s
P u b lic U n i ve rs it ie s
Click here to enter text.
Have you identified resources at any of Michigan’s Public Universities? YES ☐ NO ☐ Identify Resources and University
Have you approached those resources identified? YES ☐ NO ☐ Elaborate
Have you defined a project with a Michigan’s Public University? YES ☐
NO ☐
Elaborate
Do you require our assistance identifying resources at any of Michigan’s Public Universities?
Click here to enter text.
Small Company Innovation Program
Technology and Commercialization Assistance
VI. State of Michigan Funding Received ( Check the link for more inform ati on )
Grant Funding
Amount
M-T R A C ☐
BAF
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ETF
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S C IP
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Federal
Matching
D ARP A
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A RP A -E
O TH E R
Amount
☐
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Equit y Funding
Amount
P MV MF
☐
MA F
☐
P re -S eed Fu n d 2 . 0 ☐
VII. Attach fi rm’s Financi al Stat ements (actual and/or projected Cash Fl ow; Profi t & Loss
and Bal ance Sheet if avail abl e) and Busi ness Plan incl uding Market Intelli gence and
Technology / Manufacturing P rocesses overvi ew (all availabl e)
All information can be em ailed with t he Application to [email protected]
VIII. CEO / Owner authorization and contact info:
Signature
Direct Phone Line and Extension
Printed Name and Title
Direct Email