Name

First

Last

E-mail

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Have you ever participated in an entrepreneurial environment or startup before?

What venture or ventures are you interested in making a contribution?

Why are you interested in contributing to one, several, or all the companies we are incubating?

What is your primary area of expertise?

Note: A qualified investor is someone that has $1 million in liquid assets.

What is your current employment status?

This information will remain confidential. Your employer will not be contacted or notified of your interest.

Company Name

Job Title

How are you hoping to be compensated?

How much time per week are you willing and able to commit to?

How much reward are you hoping to achieve from your contribution?

We do not guarantee monetary gain for your contribution, but want to know what you would expect if funds do become available.

What stage of the company are you interested in getting involved

Risk / Reward tends to be the greatest for early stages, as less risk is assumed in later stages of a company's lifecycle.

What are some unique skills you have?

Examples: Proficient in programming languages for mobile application development, attorney with expertise in rental industry.

What is the URL for your LinkedIn Profile?

http://www.linkedin.com/in/...

Terms & Conditions

I understand I have not yet entered into a binding agreement with Zynergy Ventures, LLC, and have only agreed to be evaluated as a potential contributor for one of its ventures.

Ready To Do Some Exciting Stuff Together?