• Lead Source Web-to-Lead
• Record Type
• Salutation Mr. Ms. Mrs. Dr. Prof.
• *First Name
• Middle Name
• *Last Name
• Suffix
• *Company Name
• *Job Title
• *Address
• *City
• *State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• *Zip
• *County - Select One - Allegheny Armstrong Beaver Butler Fayette Greene Lawrence Washington Westmoreland Other Country Other County in PA Other State in U.S.
• County Value
• *Municipality - Select County First -
• Municipality Value
• *Phone Number
• Fax Number
• *Email
• Web Site (Use "http://")

• Additional Company Information

• If you are from outside the Pennsylvania region, why are you interested in locating here (3 sentences or less)?
• *Abbreviated company description (Describe key company products and services. Emphasize differentiating characteristics [100 words or less]).
• *Company Legal Type Corporation Non-profit Corporation Partnership Sole Proprietorship Sub-S Corporation
• If a Corporation, what are the state and date of incorporation? Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming (MM/DD/YYYY)
• *Stage of Development 1. Concept 2. Alpha Product Development 3. Service Prototype 4. Beta Test / Clinical Test 5. Shipping Product 6. Other
• Please specify
• *Number of full-time employees (total worldwide Management Team)
• Management Team
• *1. Name
• *1. Title
• 2. Name
• 2. Title
• 3. Name
• 3. Title
• Capital Investment to Date
• *Amount (in dollars)
• Source
• Investment To Date Types Angel Investor Bank Friends Other Self Venture Capital
• Angel Investor
• Bank
• Friends and Family
• Self
• Venture Capital
• Other
• Please specify
• *Investment amount that company is seeking from Innovation Works (in dollars)
• Other than capital, what are your immediate resource needs?
• Other Needs Business Mentoring Corporate Contacts Management Team Hiring Professional Services Other
• Business Mentoring
• Corporate Contacts
• Management Team Hiring
• Professional Services
• Other
• Please specify
• How Did You Hear about Innovation Works? SBDC (Please specify in detail field) Pittsburgh Business Times Post-Gazette Tribune-Review Pop City Other Press (Please specify in detail field) IW staff (Please specify the staff member in detail field) BFTDA Portfolio company (Please specify the company in detail field) Networking Online search Other referral (Please specify in detail field)
• How did you hear about Innovation Works detail?
• *Have you had contact with Innovation Works previously? Yes No
• With whom did you work?

Terms and Agreements

Innovation Works is a non-profit economic development agency serving the citizens of southwestern Pennsylvania. If we agree to provide you with business assistance, we will do so at no charge to you. We disclaim (and you waive) all warranties related to the assistance we may provide to you, and you also agree that neither Innovation Works, its directors, officers, employees nor agents shall be liable to you for any damages, including, without limitation, loss of profit or business opportunity.

• I agree