Date

Venture Name

Venture Mailing Address

• Street
• City, State ZIP

Industry/Technology

Venture Principals (list primary contact first):

Name and Role in the Venture

E-mail address

Telephone

Cellular

MIT affiliation

• Student
• Alumni
• Faculty
• Staff
• Other

If you are a student, is this venture idea based on your research at MIT? Yes No

If yes, has it been disclosed to the MIT Technology Licensing Office? Yes Yes No

Name and Role in the Venture

E-mail address

Telephone

Cellular

MIT affiliation

• Student
• Alumni
• Faculty
• Staff
• Other

Name and Role in the Venture

E-mail address

Telephone

Cellular

MIT affiliation

• Student
• Alumni
• Faculty
• Staff
• Other

Referred to VMS by

Other Entrepreneurial Activity (please check all that apply, past & present):

• Other Venture
  
• Deshpande
• i-teams
• D-lab
• 100K
• Ventureships
  
• Ideas Competition
• Other

Have you formed as a legal business entity? Yes No

Business Idea/Description

Please provide a brief (less than two pages) description of your business (or idea) and summarize its current status; it is ok to be very early in the process. Describe what it is you plan to do, who you think you will sell to, and why your product or service is useful or important. Tell us if there are any critical immediate issues you need help with. Also discuss the backgrounds and roles of the team members. Finally, it would be helpful if you can tell us what you hope to gain by working with VMS.