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1789 Membership Form
Basic Information
First Name
Last Name
UNC Email Address
Personal Email
LinkedIn Profile
Phone Number
Demographic Data
Gender
Female
Male
Non-Binary
Other
Other
Race/Ethnicity
White or Caucasian
Black or African American
Hispanic or Latino
Asian or Asian American
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Another race
Other
Preferred Pronouns
She/her/hers
He/him/his
They/them/theirs
Ze/hir/hirs
Other
Other Pronoun
UNC Affiliation
Undergraduate Student
Graduate Student
Faculty
Staff
Alumni - Undergraduate degree
Alumni - Graduate degree
Friend
Other UNC Affiliation
No UNC Affiliation
I am a current UNC student with an interest in innovation and entrepreneurship. I intend to utilize 1789 community resources such as mentors, events and networking opportunities.
Yes
Primary UNC School or Program
Please select...
BME (BioMedical Engineering)
College of Arts & Sciences
School of Dentistry
School of Education
Eshelman School of Pharmacy
Gillings School of Global Public Health
School of Information and Library Science
School of Media and Journalism
Kenan-Flagler Business School
School of Law
School of Medicine
School of Nursing
School of Government
School of Social Work
UNC Health Care
Other
Department in Arts & Sciences
Please select...
Chemistry
Biology
Computer Science
Physics and Astronomy
Mathematics
Economics
Public Policy
Environment
Other
Major/Field of Study at UNC
UNC PID Number
Graduation Year
What do you hope to gain from becoming a member of 1789?
Check all that apply to you:
I am looking to become part of the 1789 community, be inspired, and network with entrepreneurs
I would like to meet with mentors for advice
I have the beginning of an idea and would like to take the next steps
I have a current venture or business
I am interested in joining a team
I have lots of ideas—help me pick one!
Choose one:
I am completing this membership form on behalf of a venture, or idea for a venture, or on behalf of a student organization.
I am completing this membership as an individual student interested in innovation and entrepreneurship.
What is the name of your idea or venture? (If you haven't decided yet, use "NEWCO [your last name]")
If you are considering alternative venture names, please list them below.
Describe your company or idea in 500 words or less.
What industry or industries is your venture related to?
Technology
Internet/Software Services
Public Health and Human Services
Sustainability
Education
Social Entrepreneurship
Life Science
Travel
Consumer Media
Music and the Arts
Consumer Goods and Services
What are your interests and passions?
App Development
Coaching
Communications
Consulting
Design Thinking
Digital Marketing
Diversity, Equity, and Inclusion
E-Commerce
Education
Fashion
Finance
Fitness
Food
Founded a Startup
Funded a Startup
Hospitality
Human Resources
Legal
LGBTQ+ Community
Marketing
Medical / Health Sciences
Real Estate
Sales
Social Innovation
Social Media
Tech
How did you hear about 1789?
Basic Company Information
What is your company's website?
When was your company founded?
Add a second founder/team member:
Yes
No
Founder #2
First Name
Last Name
Email Address
Phone Number
UNC Affiliation
Undergraduate Student
Graduate Student
Faculty
Staff
Alumni - Undergraduate degree
Alumni - Graduate degree
Parent
Friend
Other UNC Affiliation
No UNC Affiliation
Primary UNC School or Program
Please select...
BME (BioMedical Engineering)
College of Arts & Sciences
School of Dentistry
School of Education
Eshelman School of Pharmacy
Gillings School of Global Public Health
School of Information and Library Science
School of Media and Journalism
Kenan-Flagler Business School
School of Law
School of Medicine
School of Nursing
School of Government
School of Social Work
UNC Health Care
Other
Add a third founder/team member:
Yes
No
Founder #3
First Name
Last Name
Email Address
Phone Number
UNC Affiliation
Undergraduate Student
Graduate Student
Faculty
Staff
Alumni - Undergraduate degree
Alumni - Graduate degree
Parent
Friend
Other UNC Affiliation
No UNC Affiliation
Primary UNC School or Program
Please select...
BME (BioMedical Engineering)
College of Arts & Sciences
School of Dentistry
School of Education
Eshelman School of Pharmacy
Gillings School of Global Public Health
School of Information and Library Science
School of Media and Journalism
Kenan-Flagler Business School
School of Law
School of Medicine
School of Nursing
School of Government
School of Social Work
UNC Health Care
Other
Add a fourth founder/team member:
Yes
No
Founder #4
First Name
Last Name
Email Address
Phone Number
UNC Affiliation
Undergraduate Student
Graduate Student
Faculty
Staff
Alumni - Undergraduate degree
Alumni - Graduate degree
Parent
Friend
Other UNC Affiliation
No UNC Affiliation
Primary UNC School or Program
Please select...
BME (BioMedical Engineering)
College of Arts & Sciences
School of Dentistry
School of Education
Eshelman School of Pharmacy
Gillings School of Global Public Health
School of Information and Library Science
School of Media and Journalism
Kenan-Flagler Business School
School of Law
School of Medicine
School of Nursing
School of Government
School of Social Work
UNC Health Care
Other
Add a fifth founder/team member:
Yes
No
Founder #5
First Name
Last Name
Email Address
Phone Number
UNC Affiliation
Undergraduate Student
Graduate Student
Faculty
Staff
Alumni - Undergraduate degree
Alumni - Graduate degree
Parent
Friend
Other UNC Affiliation
No UNC Affiliation
Primary UNC School or Program
Please select...
BME (BioMedical Engineering)
College of Arts & Sciences
School of Dentistry
School of Education
Eshelman School of Pharmacy
Gillings School of Global Public Health
School of Information and Library Science
School of Media and Journalism
Kenan-Flagler Business School
School of Law
School of Medicine
School of Nursing
School of Government
School of Social Work
UNC Health Care
Other
Has your company filed articles of incorporation?
Yes
No
When did you incorporate?
What is the ownership structure?
Please select...
501c
LLC - Limited Liability
C Corporation
L3C Low-Profit LLC
Fiscally Sponsored
Sole Proprietorship
S Corporation
Partnership
Benefit Corporation
Other
Company Details
Do you and your cofounders have an operating agreement?
Yes
No
Describe your company or idea in 140 characters or less.
In more detail, what does your company do or make? What is interesting or new about what your company does?
If you have a prototype or demo, please link it here:
Revenue & Funding
Do you have any revenue? If so, when do you expect to be revenue positive?
If you have not made a sale yet, when do you expect to acquire your first customer?
Have you raised any funding? If so, how much and from where (friends/family, angel/seed, prizes, etc.)?
Are you looking to raise outside funding in the next 12 months? If so, how much?
Please describe any progress or traction that you have achieved, if any. Include customers, user metrics, revenue, or any other indicators of progress.
Program Details
Have you participated in other UNC or Triangle area programs for innovation and entrepreneurship? Check all that apply.
1789 Venture Lab - Member Track
1789 Venture Lab - Venture Track
Adams Apprenticeship
BeAM - BeAMaker
BLUE
BSBA (KFBS undergraduate)
Campus Y
Carolina Challenge
Carolina Challenge Makeathon
Carolina Challenge Pitch Party
Carolina Angel Network
Carolina Creates
Carolina E(I) Lab
Carolina Kickstart Labs
Faculty Entrepreneurship Workshop
CUBE
Eshelman Institute for Innovation
Global Entrepreneurship Week
Graduate Certificate in Technology Commercialization & Entrepreneurship
Innovate Carolina
KFBS Entrepreneurship Center
KFBS Ctr Sport Business
KFBS Ctr Sustainable Enterprise
KickStart Venture Services
Launch Chapel Hill
Market Landscape Research Svc
MBA (KFBS) strategy & entrepreneurship concentration
MEITE (School of Education)
NCGrowth
NC TraCS FastTraCS
Ofc of Entrepreneurial Development(ESOP)
Reese News Lab (Media & Journalism)
Shuford Program
SoftLaunch Class (KFBS)
Startup Consulting (TCC)
StartUp-UNC (Launching the Venture)
UNC Dept of Computer Science
VC Office Innovation Eship & Econ Dev
Other MBA - evening, executive, online
Other
None
1789 Mentoring with Patrick Kastian (market research)
Startup Consulting
StartUp-UNC (formerly LTV)
Please enter the program name below:
How many hours do your employees spend on the business per person per week?
How many members of your team would you expect to work from the 1789 space?
How many hours per week will each person be working in the space?
Is there anything else you would like to tell us?
Program applying to (validation)
1789 Venture Lab - Venture Track
Contact Information