This form is used by Entrepreneurs to apply for assistance through The Appalachian Venture Foundry, an Appalachian Investors Alliance Service. This form will auto-save in your browser and can be reviewed before you submit it.

Please respond directly to each required section.  Required sections have a red asterisk next to the section name.  Feel free to cut and paste from previously created content at your discretion.  Do not respond to sections with "see referenced document", as your application will not be processed.  For those sections that are not required, we encourage you to provide what you can because our service to you will only be better with more complete information.

IMPORTANT:

The following documentation will be requested as an attachment at the bottom of this form:

Pitch Deck, Most recent Income Statement and Balance Sheet, Pro-Forma Financials (3 years minimum), Cap Table, Corporate Documents (Articles of Incorporation, By-Laws, Operating Agreement, Shareholder Agreement, Most Recent Board Minutes)

If you do not have the above documentation at this time, we encourage you to gather this information prior to beginning your application.  The more information you share, the better we can serve.

Contact Information
For this section, please enter information for the primary contact person with which the Fund should communicate regarding this application.
Who referred you to apply to the Fund?
Company Information
Legal name of the company, as registered with the State of its Incorporation, in which the proposed funds will be invested?
Please enter the name of your CEO, even if entered above as the contact person.
Please enter the year in which the company started. Note: If the company has changed the State in which it is registered, the legal structure of the company and/or the legal name under which it is registered, enter the date for the ORIGINAL entity. Commentary in the "Other Comments/Information" section below regarding these changes is appreciated.
Choose the industry that best fits your business.
Location
Please provide your company's primary PHYSICAL address below:
County in which the business resides.
Enter the number of FTE's or equivalents.
Financing Information
$
What do you estimate the value of your enterprise prior to this funding round?
Who is the lead investor in this round of funding?
$
How much are you looking to raise?
Please choose the type of financing sought.
Summarize term sheet financial and control terms to include: per-unit or per-share price, interest rate, note maturity term, discounts, valuation cap, running royalty rate and royalty base, and governance provisions, as applicable.
Provide an itemized listing and summary description of the intended use of funds requested.
$
How much have you raised to-date?
Target Closing Date
Who are your major investors (prior to this round), how much have they invested, and what type of funding facility did they use to invest?
Business Information
Please respond directly to each section.  Feel free to cut and paste from previously created content or documents within your linked document repository at your discretion.  Do not respond to sections with "see referenced document", as your application will not be processed.
Briefly describe the business' value proposition to customers, to include the problem you have identified, your solution to the problem, and why this company was founded.
Business Stage *
Simple description of the product(s) or service(s) offered.
Status of key IP (patents or trade secrets). Technology transfer and/or licensing agreements in place or under negotiation and key terms, including assignment and/or outside claims on IP. Disclosure of existing or potential IP litigation.
Market analysis to include TAM, SAM, SOM, marketing segmentation, target customer profile, and positioning (STP).
Provide details of your go-to-market strategy, including sales channels, milestones, expected sales cycle, pricing and strategy, expected margins, and plans to scale.
Who are your customers and why will they buy your product/service? Include market structure and customer segmentation where applicable.
Summarize how you will stimulate demand and close business. Please differentiate, as needed, if you are planning a multi-channel business model.
$
What was your total revenue over the last 12 calendar months?
List the direct and indirect competitors in your target market, both current and foreseeable.
In comparison to your stated competitors, provide details of how your product/service is differentiated and how you intend to leverage identified strengths and opportunities while defending against weaknesses and threats.
Provide a detailed description of the company’s exit strategy, including any projected acquiring companies, the reasoning for why these companies would seek to acquire, timelines, ROI, exit multiples, etc.
List, as applicable: Barriers to growth and/ or sustainability, such as capital to fill orders, proof of market traction, regulatory barriers, IP barriers, supply chain barriers, etc.
Share any additional details that will help the fund to understand your company and why your company would make an excellent addition to its investment portfolio. Provide URLs and/or other information references that may be helpful in understanding your business.
Please provide http links to LinkedIn profiles for your top managers (4 maximum). Identify current gaps in the team and your plan to fill them.
Add the internet address (URL) of a Dropbox folder, Google Drive folder or similar cloud-based storage of company files.
Requested Documents *
By submitting this application, you agree to provide within your document link above or via follow-up communication the required documentation listed above for processing of your application. Please check the boxes for the items you have included in your documentation room or will supply shortly.
Please tell us what assistance you are requesting from the Foundry. Be as specific in your description as you can.