Company Name *
Title *
Email Address *
Contact Person *
Phone Number *
Work Address *
City *
State *
Zipcode/Postcode *
Country *
-- Select Country --
AFGHANISTAN
ALAND ISLANDS
ALBANIA
ALGERIA
AMERICAN SAMOA
ANDORRA
ANGOLA
ANGUILLA
ANTARCTICA
ANTIGUA AND BARBUDA
ARGENTINA
ARMENIA
ARUBA
AUSTRALIA
AUSTRIA
AZERBAIJAN
BAHAMAS
BAHRAIN
BANGLADESH
BARBADOS
BELARUS
BELGIUM
BELIZE
BENIN
BERMUDA
BHUTAN
BOLIVIA
BOSNIA AND HERZEGOVINA
BOTSWANA
BOUVET ISLAND
BRAZIL
BRITISH INDIAN OCEAN TERRITORY
BRUNEI DARUSSALAM
BULGARIA
BURKINA FASO
BURUNDI
CAMBODIA
CAMEROON
CANADA
CAPE VERDE
CAYMAN ISLANDS
CENTRAL AFRICAN REPUBLIC
CHAD
CHILE
CHINA
CHRISTMAS ISLAND
COCOS (KEELING) ISLANDS
COLOMBIA
COMOROS
CONGO
CONGO, THE DEMOCRATIC REPUBLIC OF THE
COOK ISLANDS
COSTA RICA
CÔTE D'IVOIRE
CROATIA
CUBA
CYPRUS
CZECH REPUBLIC
DENMARK
DJIBOUTI
DOMINICA
DOMINICAN REPUBLIC
ECUADOR
EGYPT
EL SALVADOR
EQUATORIAL GUINEA
ERITREA
ESTONIA
ETHIOPIA
FALKLAND ISLANDS (MALVINAS)
FAROE ISLANDS
FIJI
FINLAND
FRANCE
FRENCH GUIANA
FRENCH POLYNESIA
FRENCH SOUTHERN TERRITORIES
GABON
GAMBIA
GEORGIA
GERMANY
GHANA
GIBRALTAR
GREECE
GREENLAND
GRENADA
GUADELOUPE
GUAM
GUATEMALA
GUERNSEY
GUINEA
GUINEA-BISSAU
GUYANA
HAITI
HEARD ISLAND AND MCDONALD ISLANDS
HOLY SEE (VATICAN CITY STATE)
HONDURAS
HONG KONG
HUNGARY
ICELAND
INDIA
INDONESIA
IRAN, ISLAMIC REPUBLIC OF
IRAQ
IRELAND
ISRAEL
ITALY
JAMAICA
JAPAN
JERSEY
JORDAN
KAZAKHSTAN
KENYA
KIRIBATI
KOREA, DEMOCRATIC PEOPLE'S REPUBLIC OF
KOREA, REPUBLIC OF
KUWAIT
KYRGYZSTAN
LAO PEOPLE'S DEMOCRATIC REPUBLIC
LATVIA
LEBANON
LESOTHO
LIBERIA
LIBYAN ARAB JAMAHIRIYA
LIECHTENSTEIN
LITHUANIA
LUXEMBOURG
MACAO
MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF
MADAGASCAR
MALAWI
MALAYSIA
MALDIVES
MALI
MALTA
MARSHALL ISLANDS
MARTINIQUE
MAURITANIA
MAURITIUS
MAYOTTE
MEXICO
MICRONESIA, FEDERATED STATES OF
MOLDOVA, REPUBLIC OF
MONACO
MONGOLIA
MONTENEGRO
MONTSERRAT
MOROCCO
MOZAMBIQUE
MYANMAR
NAMIBIA
NAURU
NEPAL
NETHERLANDS
NETHERLANDS ANTILLES
NEW CALEDONIA
NEW ZEALAND
NICARAGUA
NIGER
NIGERIA
NIUE
NORFOLK ISLAND
NORTHERN MARIANA ISLANDS
NORWAY
OMAN
PAKISTAN
PALAU
PALESTINIAN TERRITORY, OCCUPIED
PANAMA
PAPUA NEW GUINEA
PARAGUAY
PERU
PHILIPPINES
PITCAIRN
POLAND
PORTUGAL
PUERTO RICO
QATAR
REUNION
ROMANIA
RUSSIAN FEDERATION
RWANDA
SAINT BARTHÉLEMY
SAINT HELENA
SAINT KITTS AND NEVIS
SAINT LUCIA
SAINT MARTIN
SAINT PIERRE AND MIQUELON
SAINT VINCENT AND THE GRENADINES
SAMOA
SAN MARINO
SAO TOME AND PRINCIPE
SAUDI ARABIA
SENEGAL
SERBIA
SEYCHELLES
SIERRA LEONE
SINGAPORE
SLOVAKIA
SLOVENIA
SOLOMON ISLANDS
SOMALIA
SOUTH AFRICA
SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS
SPAIN
SRI LANKA
SUDAN
SURINAME
SVALBARD AND JAN MAYEN
SWAZILAND
SWEDEN
SWITZERLAND
SYRIAN ARAB REPUBLIC
TAIWAN
TAJIKISTAN
TANZANIA, UNITED REPUBLIC OF
THAILAND
TIMOR-LESTE
TOGO
TOKELAU
TONGA
TRINIDAD AND TOBAGO
TUNISIA
TURKEY
TURKMENISTAN
TURKS AND CAICOS ISLANDS
TUVALU
UGANDA
UKRAINE
UNITED ARAB EMIRATES
UNITED KINGDOM
UNITED STATES
UNITED STATES MINOR OUTLYING ISLANDS
URUGUAY
UZBEKISTAN
VANUATU
VENEZUELA
VIETNAM
VIRGIN ISLANDS, BRITISH
VIRGIN ISLANDS, U.S.
WALLIS AND FUTUNA
WESTERN SAHARA
YEMEN
ZAMBIA
ZIMBABWE
Has the company been incorporated? *
If your company is already incorporated, please enter the date it was incorporated(MMDDYYYY)
State of incorporation
What is the legal form of your business? *
-- Please select --
LLC
C-Corporation
S-Corporation
Partnership
Sole Proprietorship
Unincorporated
Number of employees today *
Please estimate the number of employees in 3 years *
Does the company have a business plan? *
Briefly describe your business. What market need are you solving? What is the solution you are offering? Who are your target customers? *
Do you hold proprietary rights (patents/licenses) for the technology you are developing? *
What will your monthly operating expense be for the first twelve months? (Include items such as rent, wages, inventory, phones, marketing, etc.) *
How will you fund your operation for the next 12 months? (i.e. cash reserves, credit cards, investment, operating revenue, bank loan, grant, etc) *
Have you secured any of the following to capitalize your business? *
Approximately how much space, in square feet, will you need? *
What type of space do you need? *
When do you anticipate you will need to occupy Insight Park space? *
Will you be connecting any servers to the campus network from space in Insight Park? If yes, how many and for what purpose? *
Will you be offering any Internet-based information services to consumers for a fee using systems hosted at Insight Park? If yes, please describe. *
Do you anticipate needing to transfer very large amounts of data using network services provided by Insight Park? If yes, please describe. *
If you will be conducting research that requires the use of any chemicals, please list them below. MSDS for each must be provided to Insight Park if your company is accepted. *
Please indicate what information/service connections you may request from the incubator. *
Please indicate if you have any of the following service providers. *
Are you interested in utilizing co-op students or student interns? *
If so, in what capacity? *
If you have an existing relationship with a research at the University of Mississippi, please describe that relation and the activities taking place. *
My submission of this form certifies that all the information contained herein is true and complete. *
Enter Word Verification in box below *
