1789 Membership Form

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Basic Information

First Name

Last Name

UNC Email Address

Personal Email

LinkedIn Profile

Phone Number

Demographic Data

Gender

FemaleMaleNon-BinaryOther

Other

Race/Ethnicity

White or CaucasianBlack or African AmericanHispanic or LatinoAsian or Asian AmericanAmerican Indian or Alaska NativeNative Hawaiian or other Pacific IslanderAnother race

Other

Preferred Pronouns

She/her/hersHe/him/hisThey/them/theirsZe/hir/hirsOther

Other Pronoun

UNC Affiliation

Undergraduate Student	Graduate Student
Faculty	Staff

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

Department in Arts & Sciences

Major/Field of Study at UNC

UNC PID Number

Graduation Year (anticipated)

Graduation Semester

SpringFallSummer

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 entrepreneursI would like to meet with mentors for adviceI have the beginning of an idea and would like to take the next stepsI have a current venture or businessI am interested in joining a teamI 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 characters 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 Sciences	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? (Leave blank if you do not have one yet.)

When was your company founded?

Add a second founder/team member:

YesNo

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

Add a third founder/team member:

YesNo

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

Add a fourth founder/team member:

YesNo

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

Add a fifth founder/team member:

YesNo

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

Has your company filed articles of incorporation?

YesNo

When did you incorporate?

What is the ownership structure?

Company Details

Do you and your cofounders have an operating agreement?

YesNo

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? (max 2,000 characters)

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 Mentoring with Patrick Kastian (market research)1789 Venture Lab - Member Track1789 Venture Lab - Venture TrackBeAM - BeAMakerBLUEBSBA (KFBS undergraduate)Campus YCarolina Angel NetworkCarolina ChallengeCarolina CreatesCarolina E(I) LabCarolina Innovators Connect (previously Carolina Startup Connect)Carolina Kickstart LabsEshelman Institute for InnovationFaculty Entrepreneurship WorkshopGlobal Entrepreneurship WeekGraduate Certificate in Technology Commercialization & EntrepreneurshipInnovate CarolinaInnovation Education Grant (previously Dreamers Who Do)KFBS Ctr Sport BusinessKFBS Ctr Sustainable EnterpriseKFBS Entrepreneurship CenterKickStart Venture ServicesLaunch Chapel HillMarket Landscape Research SvcMBA (KFBS) strategy & entrepreneurship concentrationMEITE (School of Education)NC TraCS FastTraCSNCGrowthNoneOtherOther MBA - evening, executive, onlineReese News Lab (Media & Journalism)Shuford ProgramSoftLaunch Class (KFBS)UNC Dept of Computer ScienceVC Office Innovation Eship & Econ Dev

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