Tenant/Client Intake Contact: techinnovationlab@uic.edu

Primary Contact First Name*

Primary Contact Email*

Primary Contact Last Name*

Primary Contact Phone

NOTE: Primary contact must be allowed to sign for the company. For University employees, please provide an appropriate email for commercial activities.

Other Contact First Name

Other Contact Email

Other Contact Last Name

Other Contact Phone

Affiliation Identify, Faculty, Staff or Student affiliation with the University of Illinois System. List institution/company in "other" if not UI affiliated.*

How did you hear about EnterpriseWorks Chicago?*

Intellectual Property Source Indicate if the IP was generated at UI or list other research institution, laboratory or company.*

University of Illinois at ChicagoUniversity of Illinois at Urbana-ChampaignOther

Conflict Management Plan Indicate if all key people have completed a conflict management plan with respective employers.*

YesNo

Intellectual Property Description Include brief description of IP, status of protection and/or license.*

Technology Sector Mark all that apply*

Life Sciences - TherapeuticsLife Sciences - Medical DiagnosticsLife Sciences - Medical DevicesHealth Care Related Information TechnologyEnergy or Clean TechnologyNon Health Care Related Information TechnologyAdvanced manufacturing, materials, devicesNanotechnology (also check if related to previously selected life science)Other

Describe the Technology/Product Include a description of the technology and potential products. (30-300 words)*

0/300

Describe the Market Include current state of problem, products/services in market and initial impressions of market opportunity. (30-500 words)*

0/500

Describe Regulatory Pathway (if applicable) (300 words)

0/300

Describe Commercialization Strategy Include brief description of initial business and technology development plan. (30-300 words)*

0/300

Describe Key People and Talent Needs Include roles and responsibilities. Identify additional skills/expertise needed to enhance team. (30-300 words)*

0/300

Describe Capital Needs Provide initial thoughts on sources, types and amounts needed and any detail on capital secured to date. (30-300 words)*

0/300

Identify support, services and resources needed. Mark all that apply.*

Commercialization PlanningSBIR/STTR Proposal Development and SubmissionRegulatory Guidance and PlanningCapitalNew Company Formation (legal, accounting, business development, branding/web design)Do not know yet, Need more assistanceOther

Identify other programs, resources, services used

Has new company been formed?*

YesNo

Company Corporate Structure

Company Name

Company FEIN

Legal Operating Address of Company

Date of Incorporation

Date

State of Incorporation

List Company Founders, Partners, Principals

Is your company in good standing with the State of Illinois?

YesNo

Number of Employees