You must have JavaScript enabled to use this form. General Information First Name Last Name Phone Email Tell Us About Your Startup Startup Name CEO Name Business Address Companies must be located in Maryland to qualify for the Maryland Momentum Fund. Street Address Street Address 2 City State StateAlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Please provide your elevator pitch in 100 words or less. Is the CEO with the company on a full-time basis? Yes No Does your startup have one or more of the following relationships? (select all that apply) Co-Founders Advisors Contractors None of the Above Is your startup incorporated? (select one) Not Incorporated C-Corp S-Corp B-Corp LLC Other Please specify. How far along is your startup? (select one) Concept Only Product in Development Revenue Generating Other Please specify. How much money are you raising in this current round and at what company valuation? If you have other investors already committed to this round, please list each investor and the amount committed. Investor Name Amount Committed Operations Investor Name Amount Committed Investor Name Amount Committed Investor Name Amount Committed Additional Information If you have received previous investment, please list each round and indicate the investors and amount of investment per round. Investment round Investor Names Total Amount Invested Operations Investment round Investor Names Total Amount Invested Investment round Investor Names Total Amount Invested Investment round Investor Names Total Amount Invested Additional Information Relationship to USM PEOPLE: USM Employee Institution InstitutionBowie State UniversityCoppin State UniversityFrostburg State UniversitySalisbury UniversityTowson UniversityUniversity of BaltimoreUniversity of Maryland, BaltimoreUniversity of Maryland, Baltimore CountyUniversity of Maryland, College ParkUniversity of Maryland Eastern ShoreUniversity of Maryland Global CampusUniversity of Maryland Center for Environmental Science PEOPLE: USM Undergraduate(s) Institution InstitutionBowie State UniversityCoppin State UniversityFrostburg State UniversitySalisbury UniversityTowson UniversityUniversity of BaltimoreUniversity of Maryland, BaltimoreUniversity of Maryland, Baltimore CountyUniversity of Maryland, College ParkUniversity of Maryland Eastern ShoreUniversity of Maryland Global CampusUniversity of Maryland Center for Environmental Science PEOPLE: USM Graduate Student(s) Institution InstitutionBowie State UniversityCoppin State UniversityFrostburg State UniversitySalisbury UniversityTowson UniversityUniversity of BaltimoreUniversity of Maryland, BaltimoreUniversity of Maryland, Baltimore CountyUniversity of Maryland, College ParkUniversity of Maryland Eastern ShoreUniversity of Maryland Global CampusUniversity of Maryland Center for Environmental Science PEOPLE: USM Alumnus Institution InstitutionBowie State UniversityCoppin State UniversityFrostburg State UniversitySalisbury UniversityTowson UniversityUniversity of BaltimoreUniversity of Maryland, BaltimoreUniversity of Maryland, Baltimore CountyUniversity of Maryland, College ParkUniversity of Maryland Eastern ShoreUniversity of Maryland Global CampusUniversity of Maryland Center for Environmental Science PEOPLE: Other Other PLACE: USM Incubator or Research Park Please select the institution the incubator is associated with and provide the incubator name. Institution InstitutionBowie State UniversityCoppin State UniversityFrostburg State UniversitySalisbury UniversityTowson UniversityUniversity of BaltimoreUniversity of Maryland, BaltimoreUniversity of Maryland, BioParkUniversity of Maryland, Baltimore Countybwtech@UMBCUniversity of Maryland, College ParkThe Discovery District (College Park)University of Maryland Eastern ShoreUniversity of Maryland Global CampusUniversity of Maryland Center for Environmental Science Incubator Name (if applicable) PLACE: RISE Zone Institution InstitutionBowie State UniversityCoppin State UniversityFrostburg State UniversitySalisbury UniversityTowson UniversityUniversity of BaltimoreUniversity of Maryland, BaltimoreUniversity of Maryland, BioParkUniversity of Maryland, Baltimore Countybwtech@UMBCUniversity of Maryland, College ParkThe Discovery District (College Park)University of Maryland Eastern ShoreUniversity of Maryland Global CampusUniversity of Maryland Center for Environmental Science IP: Based on USM Intellectual Property Institution InstitutionBowie State UniversityCoppin State UniversityFrostburg State UniversitySalisbury UniversityTowson UniversityUniversity of BaltimoreUniversity of Maryland, BaltimoreUniversity of Maryland, Baltimore CountyUniversity of Maryland, College ParkUniversity of Maryland Eastern ShoreUniversity of Maryland Global CampusUniversity of Maryland Center for Environmental Science Personal Identities We encourage applicants to provide information about personal identity should they wish to do so. Providing this information is completely voluntary and your responses provided in this section will not be used to determine funding or considered as part of your application for funding. Please use the options below to describe any way(s) in which you identify. You may select more than one option. I prefer not to answer I would like to provide freeform text instead or to supplement Female Male Nonbinary Another gender identity Black; African American; Afro-Caribbean; or of African descent American Indian or Alaskan Native East Asian or Asian Non-Hispanic white or European Of Hispanic or Latino or Spanish origin Middle Eastern or North African Native Hawaiian or Other Pacific Islander South Asian or Indian A Veteran Person with a Disability Additional Information Please Submit the Following Materials: Pitch deck or business plan (in its current form), including financial projections One file only.256 MB limit.Allowed types: txt, pdf, doc, docx, zip. The pitch deck or business plan should include the following information: Problem Solved Technology Status Product/Market Fit Risks Competition Partners Company Timeline Management/Team Full Time Equivalent Employees Use of Funds – How will you use the Momentum Fund funding and what is the next value adding milestone (often called the inflection point) at which the next financing would take place. Current Funding – Amount of funding raised by company to date, if any. Cap Table – Please indicate ownership percentages held by the current stakeholders. Intellectual Property – If applicable, please outline any IP the company holds. Exit Opportunities Proposed Term Sheet (if structured) and/or: Total Amount of round, lead investor (if any) and how much committed, amount requested from the Momentum Fund, form (e.g. convertible note, convertible preferred, equity purchase), valuation (if equity), if convertible, proposed: length of note, automatic conversion triggers, valuation cap, discount rate, interest rate Additional information about your company that you think would be helpful (optional) Additional Support What other support could the Momentum Fund provide that would be helpful in your endeavor? (select all that apply) Mentoring Access to an Entrepreneur in Residence Introductions to other investors Other Please specify.