Impact Angel Group Impact Assessment

Dear Impact Angel Group Prospective Investee,

Thank you so much for your interest in applying for funding from the Impact Angel Group. The following is intended to help us better understand the social and environmental impact of your business.

PLEASE NOTE THE FOLLOWING:

1) Since we recognize that the impact of your early stage company may be very different in the future as it is today, we have asked you to answer these questions from the current and future perspective. FUTURE is defined as the earlier of 10 years from today or the projected time for investor exit.
2) Because we want to be respectful of entrepreneurs' time, many of these questions are not required. Required questions are indicated with a red asterisk. Please do not feel obligated to answer all of the optional questions. however, if we do decide to fund your company, we may require the answers to some of the optional questions prior to making an investment.
3) We understand that it is hard to predict the future, so please give your best estimate. We expect these estimates to change over time, but would like to have a ballpark figure.
4) Lastly, please answer these questions honestly. Honesty is perhaps our most important investment criteria.

1. Survey Respondent Information:

First Name *This question is required.

Last Name *This question is required.

Title *This question is required.

Company Name *This question is required.

Street Address

Apt/Suite/Office

City *This question is required.

State *This question is required.

Zip *This question is required.

Country

Email Address *This question is required.

Phone Number

Fax Number

Mobile Phone

URL

2. Enterprise Model Impact: Does your company have any of the following enterprise models? Select from the following socially- and environmentally-focused enterprise models that describe the specific problem your company attempts to solve. *This question is required.

3. Is there any additional information you'd like to add about your company's enterprise model impact?

4. Current Local Impact: Please indicate which of the following statements are true. *This question is required.

More than 75% of the company's owners are located in Colorado
More than 75% of the company's employees reside in Colorado
The company's main production facility is located in Colorado
More than 75% of the company's significant suppliers are based in Colorado
More than 75% of company's raw materials (in dollar value) are grown or harvested in Colorado
The company purchases a minimum of 25% of its total goods and services (based on value) from businesses located in Colorado. Goods include items such as office supplies and production materials. Services may include catering, consulting, and employee training.
The company banks with a local and independent institution or a local institution that has at least 50% of their loans/deposits coming from or to Colorado
The company contributes 5% of profits or more to Colorado-based charities
None of these statements are true for our company

5. FUTURE Local Impact: Please indicate which of the following statements you expect to be true in the FUTURE. *This question is required.

More than 75% of the company's owners are located in Colorado
More than 75% of the company's employees reside in Colorado
The company's main production facility is located in Colorado
More than 75% of the company's significant suppliers are based in Colorado
More than 75% of company's raw materials (in dollar value) are grown or harvested in Colorado
The company purchases a minimum of 25% of its total goods and services (based on value) from businesses located in Colorado. Goods include items such as office supplies and production materials. Services may include catering, consulting, and employee training.
The company banks with a local and independent institution or a local institution that has at least 50% of their loans/deposits coming from or to Colorado
The company contributes 5% of profits or more to Colorado-based charities
None of these statements are true for our company

6. Current Workforce Impact: Please answer with whole numeric numbers without punctuation or symbols (i.e.: 1, 10, 100, 1000, 10000, 100000) *This question is required.

Number of employees
Number of independent contractors
Number of service providers (i.e.: legal, accounting)
Number of part-time workers
Number of full-time workers

7. FUTURE Workforce Impact: Please answer with whole numeric numbers without punctuation or symbols (i.e.: 1, 10, 100, 1000, 10000, 100000) *This question is required.

Number of employees
Number of independent contractors
Number of service providers (i.e.: legal, accounting)
Number of part-time workers
Number of full-time workers

8. Current Local Workforce Impact: Please answer with whole numeric numbers without punctuation or symbols (i.e.: 1% = 1, 10% = 10). If not applicable, write NA. *This question is required.

Percentage of part-time employees who reside in Colorado
Percentage of full-time employees who reside in Colorado
Percentage of independent contractors who reside in Colorado
Percentage of service providers who have offices in Colorado

9. FUTURE Local Workforce Impact: Please answer with whole numeric numbers without punctuation or symbols (i.e.: 1% = 1, 10% = 10). If not applicable, write NA. *This question is required.

Percentage of part-time employees who reside in Colorado
Percentage of full-time employees who reside in Colorado
Percentage of independent contractors who reside in Colorado
Percentage of service providers who have offices in Colorado

10. Current Employee Wage Information: Please answer with whole numeric numbers without punctuation or symbols (i.e.: 1, 10, 100, 1000, 10000, 100000). If not applicable, write NA.

Average part-time employee hourly wage
Average full-time employee annual salary
Total fees paid to independent contractors in last fiscal year
Total fees paid to service providers in last fiscal year

11. FUTURE Employee Wage Information: Please answer with whole numeric numbers without punctuation or symbols (i.e.: 1, 10, 100, 1000, 10000, 100000). If not applicable, write NA.

Average part-time employee hourly wage
Average full-time employee annual salary
Total fees paid to independent contractors in last fiscal year
Total fees paid to service providers in last fiscal year

12. Current Social Impact: Please indicate which statements are true.

Average Wage Requirement: The company pays an average annual wage that is equal to or exceeds the Colorado average annual wage. For the most recent average annual wage reported by the state of Colorado visit http://www.indeed.com/salary/Colorado.html
Health Insurance: The company offers and pays for at least 50 percent of the cost of health insurance premiums for all full-time employees. This coverage must, at a minimum, include major medical coverage for full-time employees and their dependents.
Diversity Support: The company is an equal opportunity employer and encourages diversity in the workforce through proactive hiring practices or through diversity training programs. These programs can include certified diversity programs, English as a Second Language (ESL) classes and Spanish classes.
Non-profit Support: The company actively supports the arts, cultural, or service non-profit sector in Colorado by: a. A commitment to donating $25 or more per year on average for each full-time employee. b. Encouraging volunteerism by granting the equivalent of at least one paid day off per year to each employee who utilizes the time to provide support to a Colorado-based non-profit entity.
Dependent Care: The company offers at least $50 per month in dependent care assistance to employees who utilize daycare or eldercare for a dependent child or other immediate family member. This may be offered as an option in a flexible benefit cafeteria plan. (Note: A pre-tax dependent care flexible spending program does not qualify.)
Housing Assistance: The company offers assistance to employees on the purchase or rental of housing located within 10 miles of their place of work. This assistance must have a minimum value of $1,000. It may be a cash benefit for down payment towards purchase or rental housing assistance to recruit new employees or retain current employees.
Wellness and Health: The company pays at least 50% of the cost of annual passes to a health club, recreational facility or wellness program (for all full time employees).
None of these statements are true for our company

13. FUTURE Social Impact: Please indicate which statements will be true.

Average Wage Requirement: The company pays an average annual wage that is equal to or exceeds the Colorado average annual wage. For the most recent average annual wage reported by the state of Colorado visit http://www.indeed.com/salary/Colorado.html
Health Insurance: The company offers and pays for at least 50 percent of the cost of health insurance premiums for all full-time employees. This coverage must, at a minimum, include major medical coverage for full-time employees and their dependents.
Diversity Support: The company is an equal opportunity employer and encourages diversity in the workforce through proactive hiring practices or through diversity training programs. These programs can include certified diversity programs, English as a Second Language (ESL) classes and Spanish classes.
Non-profit Support: The company actively supports the arts, cultural, or service non-profit sector in Colorado by: a. A commitment to donating $25 or more per year on average for each full-time employee. b. Encouraging volunteerism by granting the equivalent of at least one paid day off per year to each employee who utilizes the time to provide support to a Colorado-based non-profit entity.
Dependent Care: The company offers at least $50 per month in dependent care assistance to employees who utilize daycare or eldercare for a dependent child or other immediate family member. This may be offered as an option in a flexible benefit cafeteria plan. (Note: A pre-tax dependent care flexible spending program does not qualify.)
Housing Assistance: The company offers assistance to employees on the purchase or rental of housing located within 10 miles of their place of work. This assistance must have a minimum value of $1,000. It may be a cash benefit for down payment towards purchase or rental housing assistance to recruit new employees or retain current employees.
Wellness and Health: The company pays at least 50% of the cost of annual passes to a health club, recreational facility or wellness program (for all full time employees).
None of these statements are true for our company

14. Is there any additional information about your company's social impact that you would like to share?

15. Current Environmental Impact: Please indicate which statements are true:

The company has an employee commute trip reduction program that provide additional travel choice opportunities for employees, such as: • alternative work schedules, such as telecommuting and compressed work week programs • showers and changing facilities • secure and covered bicycle parking • preferential parking for carpools and vanpools • increased parking costs for drive alone commuters
The company has achieved a LEED Certified rating or better for its primary facility that was constructed or remodeled by or for the company.
The company has an environmental purchasing policy that dictates environmentally friendly products that should be purchased for business use. An environmental purchasing policy can include measures that require the purchase of 100% recycled paper, Energy Star office equipment and other environmentally preferable products.
The company has an office and/or facility recycling program to collect single-stream recyclable materials, including cardboard.
The company has implemented a zero waste program. Zero waste involves establishing both recycling and composting services as well as sustainable purchasing practices.
The company has conducted a detailed energy assessment by an energy engineer for its facility.
The company has purchased renewable energy credits through Green e-certified renewable energy credit (REC) providers that equal at least 25% of facility energy use.
The company has installed on-site renewable energy at their facility.
For companies that own their buildings: The company has rated their building’s energy performance using the free ENERGYSTAR Portfolio Manager online rating tool. This allows building owners, and tenants if applicable, to better understand how their building uses energy and to compare it to similar buildings nationwide.

16. FUTURE Environmental Impact: Please indicate which statements are true:

The company has an employee commute trip reduction program that provide additional travel choice opportunities for employees, such as: • alternative work schedules, such as telecommuting and compressed work week programs • showers and changing facilities • secure and covered bicycle parking • preferential parking for carpools and vanpools • increased parking costs for drive alone commuters
The company has achieved a LEED Certified rating or better for its primary facility that was constructed or remodeled by or for the company.
The company has an environmental purchasing policy that dictates environmental products that should be purchased for business use. An environmental purchasing policy can include measures that require the purchase of 100% recycled paper, Energy Star office equipment and other environmentally preferable products.
The company has an office and/or facility recycling program to collect single-stream recyclable materials, including cardboard.
The company has implemented a zero waste program. Zero waste involves establishing both recycling and composting services as well as sustainable purchasing practices.
The company has conducted a detailed energy assessment by an energy engineer for its facility.
The company has purchased renewable energy credits through Green e-certified renewable energy credit (REC) providers that equal at least 25% of facility energy use.
The company has installed on-site renewable energy at their facility.
For companies that own their buildings: The company has rated their building’s energy performance using the free ENERGYSTAR Portfolio Manager online rating tool. This allows building owners, and tenants if applicable, to better understand how their building uses energy and to compare it to similar buildings nationwide.

17. Is there any additional information about your company's environmental impact that you would like to share?