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?*
YesNo

If no, do you have a lease/license*
YesNo

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)

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?*
YesNoIn progress

Do you have projected or actual financial accounts?*
YesNo

Do you need to raise capital to operate your business?*
YesNo

If yes, amount required? ( enter value in euro )
Year 1 Year 2

How do you plan to raise funds?*

Do you require Training or mentor support from LEO or WLD (for start-ups under 12 months old only)*
YesNo

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*
YesNo

If yes give details

Has any business you owned ever ceased trading?*
YesNo

If yes, give details

Do you currently own other Businesses?*
YesNo

If yes, give details

Have you ever been convicted of a crime?*
YesNo

If yes please give details

Do you suffer any mobility difficulties?*
YesNo

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.