NBIA - New Member Application

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Do not use this form to renew an existing NBIA membership. To renew your NBIA membership, click here.

To save changes, click Save and Continue at the bottom of this page.

Your Email *:

Organization Name *:

If joining as an individual, please put your name in the top line and your college/organization (if applicable) in the second line

Org's Generic Email:

Description of Organization *:

	An Operating Incubation Program		Developing an Incubation Program
	Economic Dev Org (no incubator)		Entrepreneur Support Organization
	Former Incubator (now closed)		Government Agency (no incubator)
	Individual Member (fac, stdt or ret)		National/Regional Incubation Assoc.
	Partner		Real Estate (rent office space)
	Sponsor for Incubator(s)		State Incubator Association
	University/College (no incubator)		VC or investment based
	Vendor/Service Provider/Consultant

Since your organization currently operates a business incubation program, there is some data we would very much like you to provide NBIA. Please note: this information is NOT Mandatory in order to complete the application for membership in NBIA. We merely request that you provide information as you are able. We would prefer estimates over blank fields.

If you provide information on your incubation program, it will be used to produce industry statistics in the aggregate – your individual organization’s information will not be released. The resulting industry statistics will provide NBIA current information as we advocate for the business incubation industry, and will be available to the membership for your needs as well.

Each year, as you renew your membership on line, these questions will pre-populate with the data we currently have for your organization, so over time we hope to have the most current information available for your program.

Thank you for taking the time to provide this important data on your business incubation program!

* = required field
Questions about your incubation program
Date incubator began accepting clients (MM/DD/YYYY):

Incubator Type:

Demographic/population focus of incubator:

Incubator's geographic area :
Hold the control key to select more than one applicable item.

Incubator's primary sponsor:
Hold the control key to select more than one applicable item.

Incubator's tax status:

Industry sectors supported by incubator:
Hold the control key to select more than one applicable item.

Current number of resident clients:

Current number of affiliate/virtual clients:

Number of client companies graduating in the past 12 months :

Number of graduate client companies in the last 5 years:

Number of graduate companies still in business (even if acquired/merged):

Incubator provides pre-incubation services:

Incubator provides post-incubation services:

Number of months (average) resident clients receive services before gradation (graduates only):

Number of months (average) virtual clients received services before gradation (graduates only):

Incubator's total leasable square footage (as of close of last FY):

On average, percentage of leasable space actually leased to clients in last FY:

Total full-time jobs produced by resident clients (as of close of last FY):

Total full-time jobs produced by affiliate/virtual clients (as of close of last FY):

Total part-time jobs produced by resident clients (as of close of last FY):

Total part-time jobs produced by affiliate/virtual clients (as of close of last FY):

Total full-time jobs produced (incl owners) by graduate firms in last 5 years (at close of last FY) :

Total part-time jobs produced (incl. owners) by graduate firms in last 5 years (at close of last FY):

Total combined grant revenue (in US$) of all client companies (res. or virtual) for last complete FY:

Total combined sales revenue (in US$) of all client companies (res. or virtual) for last complete FY:

Total combined revenue (in US$) of all client companies (res. or virtual) for last complete FY:

Street Address *:

Address Line 2:

City * / State / Zip *:

Country:

Phone Number:

Fax Number:

Org Web Address:

Please sign me up for the following membership category *:

	$119 Emeritus Retired (1 member included, restrictions apply)
	$119 Student (1 member included, restrictions apply)
	$329 Individual Faculty (1 member included, restrictions apply)
	$525 Silver (1 to 3 members)
	$695 Gold (1 to 6 Members)
	$750 Consultant/Vendor (1 to 3 members)
	$995 Platinum (1 to 12 Members)
	$1,500 Corporate (1 to 4 members)

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Please provide details (i.e., site, event or person):

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