Inhite Ventures

CIQ

Condition Intake Questionnaire (CIQ) Form
Last Updated January 2009


	It takes about one minutes to complete the form. The information you provide should give us a "high-level" view of the company current condition. The information will be kept confidential. In addition, at this point, we do not need to know any details of your designs, patents, codes, secrets, etc. This is a 30,000 feet view of the company. All fields must be completed before pressing "submit". Should we contact you, we would later need to dive deep into the details.

Company:
Name:	first and last
Email:	userID@companydomain.com
Address:
State:
City:
Zip Code:

NOTE:	All fields cannot be zero (0) amount of dollars, hours, months, or investors. Instead, use the letter "z" for zero amount.

1.	How much time was spent on completing the business plan?
	hours
2.	How much time was spent on completing the five year projection?
	hours
3.	How much time was spent on completing the market research?
	hours
4.	How much time was spent on completing the executive summary?
	hours
5.	How much time was spent on completing the investment presentation?
	hours
6.	How many investors have received any of the above documents?
	investors
7.	Who normally pitches the investment opportunity to the investors?
	CEO, President, etc.
8.	How much funding did your company received from outside investors?
	$MM USD
9.	How much capital did the owner(s) contributed to the company?
	$MM USD
10.	How much capital is the company seeking now?
	$MM USD
11.	How long can the company stay in operation without outside funding?
	months
12.	What is the company expected exit strategy?
	IPO, M&A, etc.
13.	What is the company total number of committed officers?
	officers
14.	What is the valuation of the company?
	$MM USD
15.	What is your position at the company?
	CEO, President, etc.

NOTE:	Please review your inputs above and make necessary correction before moving on.

	Enter the purpose of your funding needs and any other pertinent information for the funding.
Purpose:

Passcode:
	IMPORTANT: case sensitive

NOTE:	All FIELDS must be completed before pressing "submit".

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