Cube Application Form Please complete the form below, fully and thoroughly, including anything you think may strengthen your application. Mandatory fields denoted by "*" Your Name* Company Name (if any) Company Registration No (if any) Current Business Address* Home Address* Home Phone no. Mobile phone no.* Your Email (required)* Website (if any) Do you operate from home?* Yes No If no, do you have a lease/license* Yes No If Yes what is your commencement date Expiry Date Landlord Total Space you are occupying* Reason for leaving* Date Business was established* If new, projected start up date Development stage* Concept (Business Idea Stage) Early Stage Start Up (0-12 Months) Advance start Up (12-24 months) Satellite Space (Larger Company Looking at setting up operations in Wexford) Entity Type:* Limited Company Sole Trader Partnership If Partnership, give name(s) of Partner(s) Current number of employees (including you):* Fulltime Parttime Employment Projection after 6 months:* Fulltime Parttime after 1 year:* Fulltime Parttime after 2 years:* Fulltime Parttime Do you have a business plan?* Yes No In progress Do you have projected or actual financial accounts?* Yes No Do you need to raise capital to operate your business?* Yes No If yes, amount required? ( enter value in euro ) Year 1 Year 2 How do you plan to raise funds?* Why do you require space in The Cube?* Do you require Training or mentor support from LEO or WLD (for start-ups under 12 months old only)* Yes No What experience do you have to achieve your goals* Duration you require accommodation (maxium 12 months)* Date you require space in The Cube* Are there any foreseen disturbance issues that your business could cause to other users of the Cube or Wexford Enterprise Centre? Examples: Noise, odours, etc* Yes No If yes give details Has any business you owned ever ceased trading?* Yes No If yes, give details Do you currently own other Businesses?* Yes No If yes, give details Have you ever been convicted of a crime?* Yes No If yes please give details Do you suffer any mobility difficulties?* Yes No If yes, please let us know how we can help. FINANCIAL & CREDIT INFORMATION:* Name of your bank:* Address of your bank:* Contact within your bank:* PERSONAL REFERENCE 1: Contact name:* Company Name & Address:* Phone No.* PERSONAL REFERENCE 2: Contact name:* Company Name & Address:* Phone No.* General comments you may wish to make to strengthen your application, or information we may need to know to facilitate your success with us: THANK YOU FOR YOUR INTEREST Please check your submission information carefully and click SEND when complete.