Investment Proposal – Florida Opportunity Fund

To submit an investment proposal to the Florida Opportunity Fund for consideration, please complete the information below and upload the relevant company materials for review and evaluation.

COMPANY INFORMATION

Applicant Company Name:

Parent Company (if different):

Address (Line 1):

Address (Line2):

City:

State:

Zip:

Website:

Industry:

Annual Company Revenues (last reported Fiscal Year):

Number of Employees (Full Time) in Florida:

Worldwide:

Entity Type:

Tax ID:

Request for Tax ID necessary to track participation of companies in various state and federal programs and as a unique identifier.

Non-US Owned/Controlled:

Country of Origin:

CONTACT INFORMATION

Primary Contact

First:

Last:

Title:

Email:

Phone:

Mobile:

Fax:

Secondary Contact

First:

Last:

Title:

Email:

Phone:

Mobile:

Fax:

FUNDING OPPORTUNITY INFORMATION

Total Amount of Financing:

Round of Financing:

Florida Venture Capital Program Funds Requested for this Financing?

Target Close Date of Financing:

Does the Company Currently Have Operations In Florida?:

City:

County:

Will New Florida-Based Operations Be Established Utilizing Program Funds?:

City:

County:

OTHER INFORMATION

Provide a brief description of the company/business and the proposed funding opportunity.

Description of Company/Business:

Provide the data requested below regarding Florida job creation/retention related to the proposed funding opportunity.

(Note: Please use full-time equivalents (FTEs) when calculating number of jobs created/retained and provde data as of the application date):

Current Florida based Full-Time Equivalents (FTEs):

Florida Jobs Created (FTEs) :

Year 1

Year 3

Year 5

Year 10

Year 15

Florida Jobs Retained (FTEs) :

Year 1

Year 3

Year 5

Year 10

Year 15

I hereby certify that, in my capacity as an agent/officer of the above-named applicant company, I am authorized to submit this application on behalf of such Company. I further certify that, to the best of my knowledge, all information submitted as part of this application is accurate and correct in all material respects.

Check to Indicate Certification:

First:

Last:

Title:

SUPPORTING DOCUMENTS

Detailed Description of Proposed Funding Opportunity
(File Sizes Must Be Less Than 5MB)

Attach Company Overview (Power Point Format): (Required)

Attach a Detailed Business Plan (PDF Format): (Required)

Attach a Financial Model (Excel Format): (Required)

Attach a Technical or Supporting Document (PDF Format):