35 Entrepreneurs submission form

The rules:

— The entrepreneur must be involved in running an Arizona-based business and be working in Arizona now.

— An applicant must have been born on or after Nov. 1, 1978 to be eligible.

— Entries must be submitted by 5 p.m. on Sept. 26, 2014.

— The application must be completed in full to be considered.

— Applications must be signed electronically by the entrepreneur.

— Candidates must submit a high-resolution portrait photo as part of their entry.

Name*

First Name

Last Name

Title*

Age*

Date of birth*

Hometown*

Phone*

Cell phone

Email*

Company/organization name*

Company address*

City

State

Zip Code

Website

Company headquarters location*

Primary business (i.e. software, retail)*

Year company was established in Arizona*

Is the company public?*

Number of employees in Arizona*

Number of offices in Arizona*

Do you have locations out-of-state? If so, please name

Please submit a clear head-and-shoulders photo of yourself (in .jpg or .jpeg format)*

File uploads may not work on some mobile devices.

Please answer the following questions in 150 words or less each:

Describe what your company does.*

Describe the successes you have experienced.*

Please list your company's 2012 and 2013 revenue as well as your 2014 revenue projections.*

Describe the growth your company has experienced and what spurred that growth.*

How has the economy affected your businesses, for good or bad? What changes, if any, have you made because of it?*

How have you funded your business (i.e., bank financing, personal money, venture capital, etc.)?*

What percentage of your company do you own?*

What is something that few people know about you that you think is interesting?*

Who are your business role models and why?*

What motivates you as an entrepreneur?*

What skills and attributes do you think are necessary to be a successful entrepreneur?*

What advice do you have for the next generation of entrepreneurs?*

Why should you be included in our 35 Under 35 project?*

Verification and signature

I verify that the information on this qualification form is correct and grant permission for its use on azcentral.com, 12 News, The Arizona Republic and all other Republic Media platforms.*

I agree.

Enter your initials here*

Date of application*

Please fill in a valid value for all required fields

Please ensure all values are in a proper format.

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