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Application for Resident or Non-Resident (Affiliate) admission to the Coastal Bend Business Innovation Center Incubation Program

* = Required Field

* Resident or Non-Resident
  Facility Name: Coastal Bend Business Innovation Center
* Company Name:
* Contact First Name:
* Contact Last Name:
  Is spouse active in the business? No    Yes
  Spouse's Name (if applicable):
* Address 1:
  Address 2:
* City:
* State:
* Zip Code:
* Phone Number:
  Fax Number:
* Email:
  Are you currently or do you have future plans to receive 75% of total revenues from outside Nueces or San Patricio counties? No    Yes
  List all persons with 20% or more ownership in the company:
  Form of Business: Sole Proprietorship
Incorporated
Partnership
LLC
Not incorporated at this time
Other
  Year Business Started:
* Company Type:
* Product & Service Description
(Paste Business Plan if available)
  How did you hear about us? Direct Mail
Newspaper
Radio
Billboard
Magazine
Internet Search Engines (Goolge™, etc.)
Referral
Name:
Company/Organization:
Other
* Desired Date of Admission:
 
All of the information provided in this inquiry is accurate and complete to the best of my knowledge and I am authorized to release this information. I certify that I have not submitted any confidential or proprietary information and acknowledge that no confidential relationship has been established with the Coastal Bend Business Innovation Center.
I agree
 
 
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