First Name
Last Name
Your company name
Your role at the company
What does your company do?
Please provide your contact information.
City
State
Zipcode
Phone
Email
Website
How did you hear about ICA?
ICA Newsletter
ICA Staff Member
Entrepreneur who took an ICA Fund Good Jobs offering
Social Media
Other
Specifically, who can we thank for referring you to us?
Specifically, what platform?
Over the next three years, how many jobs do you plan to create?
0 - 5
6 - 15
16 - 30
31 - 50
50+
What is your most recent yearly revenue?
Pre-revenue
$0 - $10k
$10k - $50k
$50k - $100k
$100k - $200k
$200k - $500k
$500k+
What is your projected revenue next year?
Pre-revenue
$0 - $10k
$10k - $50k
$50k - $100k
$100k - $200k
$200k - $500k
$500k+
Describe your main business challenge, in 200 characters or less.
In the next 12-18 months, do you plan to seek outside capital to help grow your company?
Yes
No
How much capital do you plan to seek (in USD)?
What would you like to tell us about?
Can we send you occasional emails with ICA news and information about upcoming events?
Yes.