Tenant/Client Intake Contact: Kapila Viges, Director ewchicago@uillinois.edu

Tenant/Client Intake Contact: ewchicago@uillinois.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. *

Faculty/Staff UIC Student UIC Faculty/Staff UIUC Student UIUC

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 Chicago University of Illinois at Urbana-Champaign

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

Yes No

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

Technology Sector Mark all that apply *

Life Sciences - Therapeutics Life Sciences - Medical Diagnostics Life Sciences - Medical Devices Health Care Related Information Technology Energy or Clean Technology Non Health Care Related Information Technology Advanced manufacturing, materials, devices Nanotechnology (also check if related to previously selected life science)

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 Planning SBIR/STTR Proposal Development and Submission Regulatory Guidance and Planning Capital New Company Formation (legal, accounting, business development, branding/web design) Do not know yet, Need more assistance

Identify other programs, resources, services used

Has new company been formed? *

Yes No

Company Corporate Structure

Limited Liability Company S-Corporation C-Corporation Partnership

Company Name

Company FEIN

Legal Operating Address of Company

Date of Incorporation

Date Date Picker Icon

State of Incorporation

List Company Founders, Partners, Principals

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

Yes No

Number of Employees