Full Name *

Title

E-Mail *

Phone Number *

Fax Number

Business Name

Business Address

City

State

Zip Code

Business Website

Year Company Started

Legal Entity

Current Number of Employees

NAICS Code (if known)

Business Description *

Revenue 2021 *

Revenue 2022 *

Revenue 2023 *

Projected Revenue 2024 *

Are you able to make a commitment to participate in a CEO roundtable group approximately three hours/every month plus visits to your business?YesNo

In consideration of the counselor(s) and members of CEO XChange/Florida SBDC at UCF furnishing management or technical assistance, I waive any and all claims for loss, damage or injury against FSBDC and its employees, agents, volunteer advisors and host organizations, arising from or in connection with this assistance. *

I understand an administrative fee of $600 will be due upon acceptance to the program. The fee also covers the cost of breakfast meetings *

Applicant’s Initials *