Genesis Group Questionnaire

First Name

Last Name

Email:

Phone:

Company Name:

Title/Role:

Area of expertise (industries/sectors/subject matter)

Start-up experience

Reason for interest in Genesis Group

Do you currently have an App or a Tech Start-up idea you would like for Genesis Group to consider?

Yes

No

Are you an Accredited Investor as defined by SEC Regulation D?

Yes

No

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