*Your provision of information does not create a lawyer-client relationship between yourself and Miller Thomson LLP (“MT”), nor render MT subject to any duty of confidentiality at this stage of the process. As such, please refrain from disclosing any information or materials that you consider confidential in the context of your application to the MTech Program.

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* 1. Business name

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* 2. Contact name

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* 3. Contact e-mail

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* 4. Contact telephone number

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* 5. Website

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* 6. Please provide a short description of the business

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* 7. Please provide a list of all founders and any shareholders

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* 8. How much capital have you raised to date?

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* 9. What were the sources of capital (if any)?

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* 10. What was the company's revenue in the past 12 months

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