ECCI ACCELERATOR (STAGE 2) PROGRAMME

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1. ABOUT YOU
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2. Full name: *

3. Company name: *

4. Personal address (if applicable): *

Street address	*
Street address line 2	*
City	*
Postcode	*

5. Your country of residence: *

6. Business address (if different):

Street address
Street address line 2
City
Postcode

7. Business contact email (if applicable):

8. Business contact phone number (if applicable)

9. Company founder 1 (e.g owner, CEO): *

Name:	*
Role:	*

10. Company founder 2 (e.g owner, CEO) (if applicable):

Name:
Role:

11. Tell us about your start up mission (max 100 words): *

12. Which theme is most applicable to you? *