First Name *

Last Name *

Phone 1 *

Email *

Residential Address Line 1 *

Residential Address Line 2

City *

State/Province * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

Zip/Postal Code *

Country * United States of America Canada Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia (Plurinational State of) Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo (the Democratic Republic of the) Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czechia Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands [Malvinas] Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea (the Democratic People's Republic of) Korea (the Republic of) Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia (Federated States of) Moldova (the Republic of) Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Macedonia Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Réunion Romania Russian Federation Rwanda Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Sweden Switzerland Syrian Arab Republic Taiwan (Province of China) Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Türkiye Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom of Great Britain and Northern Ireland United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela (Bolivarian Republic of) Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Western Sahara* Yemen Zambia Zimbabwe

Business Name

Business Website

Business LinkedIn Link

Business Facebook Link

Business Instagram Link

What is your gender? *

Age Range (used only for program reporting and impact tracking) *

What is your race/ethnicity? Black or African American White Hispanic or Latino/a/x Asian Native American or Alaska Native Native Hawaiian or Other Pacific Islander Middle Eastern or North African Multiracial or Mixed Race Other Prefer not to say

Do you currently live in Mecklenburg County? *

If not, which city do you live in? *

How many people currently live in your household? 1 2 3 4+

Please review the household income limits below and indicate whether your total family household income falls below the applicable threshold for the number of individuals living in your home?

Please provide additional information explaining your answer above (optional).

Describe your business in a few sentences. *

Which of the following best describes your business vertical? *

Describe your ideal customer or target market. *

Are you currently working full time on your startup? *

If not, when do you anticipate transitioning full-time? *

Do you have any team members? *

If yes, please list their names and roles.

How many employees do you expect to hire in the next 3 years? * 0 1–2 3–5 6–10 11–20 21–50 51–100 100+

What was your business’s top line revenue in the last 12 months? * Pre-revenue Less than $10,000 $10,000 – $49,999 $50,000 – $99,999 $100,000 – $249,999 $250,000 and above

What is your business address (if different from your residential address)? *

How did you hear about the Boost Pad? *

Were you referred by a community partner or individual? *

If yes, please share their name so we can thank them. *

Are you able to pay the $200 enrollment fee? *

Please upload a 2-minute video introducing yourself and your business. *