American Dream Makers Scholar Interest Form

Astronaut Scholar Name*

First NameLast Name

Age

ASF Alum University/ College*

First Year Selected as Astronaut Scholar*

Second Year Selected as Astronaut Scholar (if applicable)

E-mail*

Preferred Phone Number*

Area CodePhone Number

Alternate Phone

Area CodePhone Number

Work Number

Area CodePhone Number

Employer (if applicable)

Technology Transfer

It is important for ASF to understand the status of any intellectual property that may be used in development of your innovation. Please indicate the level of ownership or permission that you possess. If you are unsure, indicate so, and we will assist you in making a determination.

Technology Transfer and Intellectual Property release status

Legally cleared by university, employer, or partner to use or share idea, concept, technology, innovative approach, etc. with Innovators Corps so they may advise and mentor meI own/established the idea, concept, technology, innovative approach, etc. and am free to share with the Innovation Corps so they may advise and mentor meI do not knowOther

My reason for reaching out to the American Dream Makers Innovation Corps is (I need help/advice with ...)*

My general idea is (high level discussion about concept, idea, technology)*

Additional Comments

In accordance with federal law and U.S. Department of the Treasury policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability.

To file a complaint of discrimination write to the Direct – Office of Equal Opportunity and Diversity, 1750 Pennsylvania Avenue, NW, Washington, DC 20220. The Department of the Treasury is an equal opportunity provider and employer.