Technical Assistance Intake

1 Business Information

Business name*

Please enter your business name.

Primary contact name*

Please enter a contact name.

Title or role

Email address*

Please enter a valid email address.

Phone number (optional)

County*

Klamath County Lake County

Please select a county.

City

2 Business Profile

Business stage*

Idea stage Early stage (pre-revenue or early revenue) Growth stage Established business seeking innovation or expansion

Please select a business stage.

Industry sector

Technology Agriculture or Natural Resources Healthcare or Life Sciences Manufacturing or Trades Creative or Services Retail or Hospitality Other

Years in operation

Not yet operating Less than 1 year 1 to 3 years 4 to 10 years More than 10 years

Number of employees (including owners)

3 Assistance Requested

Select all that apply.

Business strategy Financial modeling or capital readiness Operations or systems Product or service development Market research Pitch or presentation support Regulatory or compliance Other

4 What You Need Help With

Briefly describe the challenge or project*

Please describe what you need help with.

What outcome would make this assistance a success?

5 Scheduling Preferences

Preferred session format

In person Virtual Either

Preferred timeframe

Within 2 weeks Within 30 days Within 90 days Flexible

6 Referral Source

How did you hear about the Innovation Hub?

Oregon Tech Ecosystem partner Event or workshop Website or online search Referral from another business Other

7 Consent and Acknowledgment

Please acknowledge to continue.

Name*

Please enter your name.

Date

1 Business Information

2 Business Profile

3 Assistance Requested

4 What You Need Help With

5 Scheduling Preferences

6 Referral Source

7 Consent and Acknowledgment

Thank you. Your request has been received.