SUP FIU Food Retail Certificate

Please state “N/A” regarding any questions you are unable to answer.
Main Contact Name: Main Contact Name: First Last
Business Name:
Business Mailing Address: Business Mailing Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Mailing Address: Home Mailing Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Work Phone: Work Phone: - ### - ### ####
Home Phone: Home Phone: - ### - ### ####
Fax Phone: Fax Phone: - ### - ### ####
Cellular Phone: Cellular Phone: - ### - ### ####
Email:
Website:
Year business was founded:
Year you acquired ownership:
What percentage of the business do you own?
Employee Count: Full Time
Employee Count: Part Time
Annual Gross Revenues: Year-to-date
SUP FIU FOOD Alumni

SUP FIU FOOD Alumni Program Alumni Business Support FIU Employee Community Development Organization Services (Business Associations, Chamber of Commerce, Small Business Development Center) Media Website Other (Please specify below) Other (Please specify below)
Briefly describe your product.
Do you have a working business plan?

Do you have a working business plan? Yes No
Upload Business Plan (5MB limit):

Attach Files

If greater than 5MB, please email your business plan to Foodfiu@fiu.edu with your company name as the subject.
If you do not have a business plan, please explain below:
Describe your target market (provide examples of former or current customers):
List all members of your team (include name, title, and role):
Personal Information

The following questions are optional. Your answer will help track the demographics of applicants and participants.
The information is voluntary and will not be used when considering you for employment with our company.
Racial or Ethnic Group:

Racial or Ethnic Group: American Indian/ Alaskan Asian/ Pacific Islander Black/ African American Hispanic/ Latino White/ Caucasian Other
Gender:

Gender: Male Female
Were you born in the United States?

Were you born in the United States? Yes No
If born outside of the U.S., please indicate country of origin:
I understand that this application does not imply acceptance into the StartUP FIU- Food's Kitchen Incubator program, or acceptance as a commercial user. I also verify that the information provided is complete and accurate to the best of my knowledge.
Emergency Contact Information
Emergency Contact #1: Emergency Contact #1: First Last
Relationship:
Phone: Phone: - ### - ### ####
Email:
Emergency Contact #2: Emergency Contact #2: First Last
Relationship:
Phone: Phone: - ### - ### ####
Email:
I confirm that the above information is accurate. I understand the confidentiality policy and hereby give permission to StartUP FIU- Food staff to use my information for program evaluation and reporting purposes.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

SUP FIU Food Retail Certificate

Please state “N/A” regarding any questions you are unable to answer.

Personal Information

I understand that this application does not imply acceptance into the StartUP FIU- Food's Kitchen Incubator program, or acceptance as a commercial user. I also verify that the information provided is complete and accurate to the best of my knowledge.

Emergency Contact Information

I confirm that the above information is accurate. I understand the confidentiality policy and hereby give permission to StartUP FIU- Food staff to use my information for program evaluation and reporting purposes.