INVEST ILLINOIS VENTURE FUND APPLICATION ILLINOIS DEPARTMENT OF COMMMERCE AND ECONOMIC OPPORTUNITY

Please complete this online form and attach the appropriate paperwork as described.
* designates a mandatory field.
Do not use the following characters in the text fields or the document names: &, < or >.
ONLY attached documents with the following extensions:
txt, xls, xlsx, pdf, doc, docx, rtf, jpg and gif
File size per attachment cannot exceed 2MB per attachment.
Do not attach a document more than one time.

COMPANY/CONTRACT INFORMATION

1 - Company Name:*

2 - Company Address:*

3 - Company's FEIN#(Do not enter Social Security Number):*

4 - Name and address of parent company (if applicable):

5 - Name and title of primary contact:*

6 - Mailing address of primary contact:*

7 - Contact phone and fax of company primary contact:*

8 - Contact email of company primary contact:*

9 - Select from drop-down box or type in Relationship of Primary Contact to company:*

10 - Contact name, mailing address, phone and email of sponsor or referral contact (if applicable):

11 - Number of employees worldwide (please specify how many FTE, part time, and independent contractors as applicable):*

12 - Number of employees in Illinois (please specify how many FTE, part time, and independent contractors as applicable):*

13 - DUNS#(9 digits including the leading zeros):

14 - UIA#(Unemployment Insurance Account Number. Every business with employees in Illinois must register with IDES and file unemployment insurance contribution (tax) reports each quarter. Employers who are subject to the Illinois Unemployment Insurance Act supply the funds IDES uses to pay benefits to the unemployed.):

15 - Attach W-9 Form (File size cannot exceed 2MB):*

This is a mandatory field

MARKET & INVESTMENT INFORMATION

16 - Select from drop-down box of Company's primary sector focus:*

17 - Select Company Stage:*

18 - Attach lead investor term sheet, conditional and/or qualified private third-party investment commitment (please include contact information, amount and deal terms. File size cannot exceed 2MB):*

This is a mandatory field

19 - Select Round of current financing:*

20 - Total amount being raised:*

21 - Target date to close financing:*

EXECUTIVE BUSINESS SUMMARY

22 - Brief background and description of what the company does (500 characters or less):*

23 - What is the unmet customer need and problem solved? (500 characters or less):*

24 - Description of the product, IP status and differentiation compared to competitors? (500 characters or less):*

25 - Does your company have trade secrets not currently protected by patent or other copyright protection? (yes/no):*

26 - Include short bio of key management personnel (1000 characters or less):*

GUIDELINES FOR THE BUSINESS PLAN, FINANCIAL PRO-FORMA AND THE LEAD INVESTOR TERMS DOCUMENTS

With the application the company may also submit in separate attachments the following documentation. Applications will be accepted in PDF MS WORD format ONLY.

BUSINESS PLAN SUMMARY (UP TO 5 PAGES)

1. Company Information
1.1 Name
1.2 Name of company contact
1.3 Brief description of what the company does

2. Market Information
2.1 Description of market need to be met, together with any supporting data.
2.2 Description of customer to be served
2.3 Customer validation to date for proposed product
2.4 Noteworthy trends in target market
2.5 Size and growth rate of target market
2.6 Major competitors in target market
2.7 Anticipated or current partners in production or delivery of proposed product
2.8 Go-to-market strategy (if not in the market yet)

3. Product Information
3.1 Description of product
3.2 Intellectual property/patent portfolio
3.3 Cost/benefit analysis compared to competitor's validation of the technology
3.4 Status of product development and projected timeline to market

4. Management
4.1 Relevant experience and detailed biographies of management team **
4.2 Summary bios of the Board of Directors and Advisory Board(s) (if any) **
4.3 Key vacancies and plans to fill them, including timing of additions
4.4 Job creation projections for the next 3 years

Attach Business Plan Summary Document (File size cannot exceed 2MB):

FINANCIAL PRO-FORMA DOCUMENT

Financial statement for the last two (2) years (if any) **
Forecasted revenue and profit for at least 3 years (month-month for first year) **
Financing required to fund the forecast, how much being sought in this round and fundraising activities completed to date

Financial Pro-forma Document (File size cannot exceed 2MB):

TERMS AND CONDITIONS

NO GUARANTY OF FUNDING:
Submission of an application and the materials requested therein by any individual or entity (collectively, an "Applicant") to the "Invest Illinois Venture Fund Program," managed by the Department of Commerce and Economic Opportunity ("DCEO") including all books, papers, digitized electronic materials and databases, regardless of physical form, made, produced, executed or received by DCEO in connection therewith (collectively, the "Materials") will constitute a request by an Applicant that DCEO review the Materials and determine if DCEO will invest in the Applicant. Submission of the Materials to DCEO, or confirmation that all requested materials have been provided, shall not constitute either (i) an acceptance or offer of funding by DCEO, or (ii) a commitment that DCEO will invest in the Applicant. In the event that the Applicant provides all of the requested Materials, and if in the sole discretion of DCEO, including its agents and advisors, the Applicant constitutes a suitable investment for DCEO, then DCEO may offer to invest in the Applicant on terms and conditions that DCEO, in its sole discretion, shall set forth in writing (the "Offer"). DCEO shall have no obligation to offer to invest or to negotiate the terms and conditions of any Offer, and any attempt by the Applicant to negotiate the terms of any Offer shall constitute a rejection of the Offer by the Applicant.

CONFIDENTIALITY OF INFORMATION:
All Materials (defined above) submitted to DCEO will become and remain the property of the State of Illinois. DCEO has no obligation to keep the Materials confidential. DCEO has no obligation to notify the Applicant (defined above) of any third-party requests for copies of or information regarding the Materials. Materials that the Applicant reasonably believes are trade secrets or are proprietary, privileged or confidential in nature, and where disclosure of the same would cause competitive harm, may be so marked by the Applicant before submitting the Materials to DCEO. DCEO will use reasonable efforts not to disclose the Materials so marked to third parties who are not involved in facilitating DCEO's investments. DCEO makes no representation or warranty that it will be successful in either keeping any of the Materials so identified confidential or otherwise prevent their disclosure to third-parties. DCEO is obligated to respond to all Freedom of Information Act requests. DCEO disclaims liability for any and all direct and/or indirect damages that may be incurred directly or indirectly by the Applicant as a result of the disclosure of the Materials.

NO RETURN OF INFORMATION:
None of the Materials (defined above) submitted to DCEO by or for the Applicant (defined above) will be destroyed, removed or otherwise disposed of except as permitted by the laws of the State of Illinois, including the State Records Act (5 ILCS 160/1, et seq.). No Materials, and no copies thereof, will be provided to, or returned to, any Applicant except as provided by Illinois law.

If you agree with the TERMS AND CONDITIONS please check the box.

Enter the code shown above: