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Request for Funds Submission Form

Please fill out the following form as completely as possible.

We will respond to all requests for funds within one month of receiving your complete submission.

Company Name*
Your Name*
Your Title*
Email Address*
Phone Number*
Funds you are seeking*
Use of funds*
What industry are you in?*
Product Details

Please include any relevant details of your product such as if you have filed any patents, clinical trials or FDA approval will be necessary, etc.
What is your target market?*
What is your time to market?*
What need do you satisfy?*
Potential revenue in 5 years*
Executive summary*

Please provide your executive summary in the box above.
Key personnel biographies*

Please provide a brief biography on the key personnel involved above.
Comments

Please provide any other relevant information you would like Fox Ventures to know about your company.
Fox Development Corporation • FDC LLC • Fox/Atkins Development, LLC
1909 Fox Drive, Champaign, Illinois 61820
Ph (217)351-1430  •  Fx (217)356-0556  •  info@fox-companies.com
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