Intake Form - Entrepreneurship Law Center

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Fields

Personal Information

Name*

First Name*

Last Name*

Title

Address*

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Email*

Primary Phone: *

[XXX-XXX-XXXX]

Alternate Phone:

[XXX-XXX-XXXX]

Are you a faculty member, student or alumni of any of the following organizations? (Check all that apply)*

University at Buffalo Roswell Park Comprehensive Cancer Center Kaleida Health Hauptman Woodward Institute Jacobs Institute WIN (Western New York Incubator Network)

What is your affiliation with the University at Buffalo? (Check all that apply)*

Faculty Staff Resident Fellow Student Alumni N/A

Other: Other Value

Academic Department or Degree/Major:

Graduation Date or Expected Graduation Date: [MM/YYYY}

Does your business idea involve an invention created with University at Buffalo resources?*

Yes No

Does your business idea involve an invention created in your scope of employment?*

Yes No

Has your invention been disclosed to the Technology Transfer office?*

Yes No

Do you intend to disclose the technology to Technology Transfer office?*

Yes No

Business Information

Is your business/entity already formed?*

Yes No Not sure

Legal name of business

If not currently formed, what is the current working name of the entity?

Business d/b/a (if applicable)

Is the business currently operational?*

Yes No

Type of Enterprise*

For profit Not-for-profit Social enterprise (benefit corporation/”B-Corp”, flexible purpose corporation, etc.) Not sure

Industry [Check all that apply]*

Aerospace Agriculture Apparel Chemicals Communications Computer Construction Consulting Consumer Goods Defense Distribution Education Electronics Energy Engineering Entertainment Environmental Finance Food, Beverage and/or Tobacco Government Healthcare Hospitality Information Technology Insurance Life Sciences Manufacturing Marketing Media Medical Mining Not for Profit Printers Real Estate Recyclers Retail Schools, Colleges & Universities Services Technology Telecommunications Toys Transportation Utilities Wholesale Trade

Other: Other Value

Business Address

Address Line 1

Address Line 2

City

State

ZIP Code

Business Website

Social Media Pages

Please describe your business idea:*

Do you have a business plan, executive summary or pitch deck?*

Yes No

Do you have any partners or investors in your business?*

Yes No

List Names & Emails of Partners:

Do you or anyone on your team identify as the following:*

Woman/Women Owned Minority Owned Veteran Owned LBGTQ+ Owned N/A

Check all that apply

If yes, are you certified as an MWBE in New York State?

Yes No

If you are not certified, please state your basis for being an MWBE

Accountant:*

How is your business being financed?*

Have you or anyone on your team ever been determined to be a “Bad Actor” as defined by the Securities and Exchange Commission? *

Yes No I do not know

How did you hear about the e-Law Center?*

Have you applied previously to work with the e-Law Center?*

Yes No

What type of service(s) are you interested in at this time?*

Commercial Contracts Conflicts of Interest Entity Selection and Formation Ethics Financing Governance Hiring & Employment Matters Intellectual Property (trademarks, trade secrets, copyrights and licensing) Privacy Policies Securities Small Business Advice and Counseling Social Enterprises Tax Terms of Use

Other: Other Value

Check all that apply

Why you are interested in working with the e-Law Center and what do you hope to achieve? (Please provide specific needs looking to address)*

When do you hope to commence work with the e-Law Center?*

ASAP 2-3 Weeks 1-3 Months 3-6 Months 6-12 Months

Other: Other Value

Preferred Contact Method:*

Phone Email

Other: Other Value

Are you affiliated with any of the following organizations/programs [check which apply]

43North Launch NY Z80 Incubator Labs Harrison Place Business Center UB BioSciences Incubator UB Technology Incubator BNMC Innovation Center DIG UB Directed Energy (virtual incubator) Fredonia Technology Incubator Olean Business Incubator IncubatorWorks Alfred UB I-Corps UB Blackstone Launchpad Founders Institute

Check all that apply

By voluntarily completing the e-Law Center Client Application, certain personal information is collected from you. This information, along with any application supplements and/or other applicant documents may be used to complete your application. Information collected may include your name, home and mailing address, email address, telephone number, university affiliation, potential and/or current business information. This information may be shared with the University at Buffalo Business and Entrepreneur Partnerships (BEP), iHUB and/or its affiliates.*

Please initial to acknowledge this statement

By submitting this application, you understand that there is no attorney-client relationship or other business relationship between you and the University at Buffalo School of Law’s Clinical Legal Education attorneys, iHUB, BEP and/or its affiliates.*

Please initial to acknowledge this statement

By voluntarily completing the e-Law Center Client Application, applicant certifies that they understand the e-law Center is an educational program that offers a community service while providing practical experience for law students under the supervision of one or more University at Buffalo School of Law faculty members who are licensed to practice law by the State of New York. In this experience, law students are certified by the Supreme Court of the State of New York – Appellate Division, 4th Judicial Department, and are acting as lead attorneys and will be the main primary contact for all case matters. Should applicant choose to accept representation, they understand that they are agreeing to work with e-Law Center Clinic Student Attorneys for the duration of their time as clients with the e-Law Center Clinic.*

Please initial to acknowledge this statement