REaKTOR Client Application

I. General Information

Your Name(Required)

First Last

Date Formed Taxpayer I.D. #

Business Address

Street Address Address Line 2 City ZIP Code

Preferred Method of Contact

Phone(Required)

Work

Home

Your Email Address(Required)

Email Address Confirm Email Address

Website

Current Hampton Business License?(Required)

Yes

Business Structure(Required)

Individual/ Sole Proprietor

Corporation

LLC

Sub S Corp.

Non-Profit Org.

Partnership

Principal Business Owner(s) that are greater than 20% ownership

(Use additional pages if required)

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Ownership %

Please enter a number from 1 to 100.

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Ownership %

Please enter a number from 1 to 100.

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Ownership %

Please enter a number from 1 to 100.

Is the business currently in operation?(Required)

Yes

If yes, year founded

If no, where are you employed?

Do you have a business plan?

Max. file size: 32 MB.

If yes, please attach business plan

Do you have a business plan?

If no, when do you plan to have one completed?

Do you have general liability insurance coverage?(Required)

Yes

If yes, name of company

II. Information on Business Product/Service

Briefly describe your product or service:(Required)

Briefly describe the market for your product/service (your target customer):(Required)

In what geographic area(s) are the majority of your customers located?(Required)

Who are your competitors? (Name at least two)(Required)

Why do you think you have a competitive advantage?(Required)

III. Business Experience

Describe your experience that relates to your product/service and the length of that experience (attach a resume if available):(Required)

List the names and titles of any other officers or key personnel (attach resumes if available):(Required)

File

Max. file size: 32 MB.

File

Max. file size: 32 MB.

File

Max. file size: 32 MB.

IV. Business Service Needs

What type of needs do you feel are needed to help achieve a successful venture?(Required)

V. Facility Requirements (if you are not seeking a facility, please skip to section VI)

Are you currently occupying a facility (either in your home or at a commercial location)?

Yes

If yes, what is the approximate square footage?

Sq.Ft.

Rent

Utilities

How many square feet of space does your business require?

Sq.Ft.

Please describe any special requests that are needed on the premises and what service support is needed to maintain this equipment.

If accepted as a tenant, when would you want to start occupancy in the facility?

How many employees will be occupying the space?

Part-Time

Full-Time

Total number of employees employed by your business

VI. Other

How did you learn about REaKTOR?(Required)

How do you think your participation in REaKTOR will benefit your business?(Required)

VII. Business Financial Information

Initial Capitalization(Required)

Less than $10,000

$10,001 to $25,000

$25,001 to $50,000

$50,001 to $100,000

$100,001 to $500,000

Over $500,000

What are your projections for total gross revenue/sales?: Year 1(Required)

Year 2(Required)

Year 3(Required)

What is the amount and source of financing for operating your business?(Required)

Existing Loan(s) Amount:(Required)

Cash/Equity Amount:(Required)

Other Amount:(Required)

Operating Expenses are/will be covered by sales:(Required)

Are you currently seeking additional funding for your business?(Required)

Yes

If yes, please state the amount of funds needed:

Where do you plan to obtain these funds?

Please list your personal or business bank information as follows:

Bank Name/Branch

Phone

Representative’s Name

VIII. References

Please provide three (3) professional references as follows:

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

I, the undersigned, am applying for admission to REaKTOR. I understand that the information contained in this application will be held in the strictest of confidence. I understand that, as a part of the screening process, my credit history and financial references may be investigated. By signing this document, I give authorization to REaKTOR Management to do so. I understand that this application is subject to review in all areas and in no way guarantees my admittance to this program and that no liability will be assumed by REaKTOR.

Initial