Black Ice Pitch Application

First Name

Middle Name

Last Name

Female Male

City

Department

Country

Phone Number

Alternate Phone Number

Name of Business or Organization:

Department (Business location)

How long has your company been in operation?

Is your business legally registered in Haiti?

Yes

Please attach copy of registration or patent certificates

Industry

Ex: Agriculture, Textile, Construction, Healthcare, etc..

Description of what your company or organization does:

What problem is your organization solving or seeking to solve?

Emergency Contact (Haiti)

First Name (Emergency Contact, HT)

Last Name

Phone Number

Email Address

If applicable

Street Address

City

Postal Locality/District/Department

Country

Emergency Contact (United States)

First Name (Emergency Contact, US)

Last Name

Street Address

City

Country

Phone Number

Email Address

If applicable

*PLEASE EMAIL VIDEOS to info@belinitiative.com (include applicant and business name in email)

Please attach supporting documents

Check off list

Copy of U.S. Visa (if applicable)

Submit pitch video via email to info@belinitiative.com

WE WILL NOT CONSIDER INCOMPLETE APPLICATIONS

By providing my signature and checking the box below, I understand that If I have misrepresented or omitted any facts relative to this application, I can be denied or discharged from this program. I also commit to helping Haiti become a developed nation through my talents and efforts.

*There are NO FEES to apply or participate in the program if you are selected*

You must check the box to proceed

I Understand & Agree

Signature

Date

How did you learn about Black Ice?

Comments are closed.

Cart

Black Ice Pitch Application

Emergency Contact (Haiti)

Emergency Contact (United States)