Company Application

Company Name *

Contact Information

Title *

Phone *

Fax

Email *

Business Information

Address

Street Address

Address Line 2

Website *

Federal Employer Identification (EIN) *

Date Founded *

Current TRL of Technology *

Current Number of Employees *

Company Legal Status (select one) * C CorpS CorpLLCOther

Please list business license # and municipality *

What category best describes your company (select one) * Agriculture/Food TechnologyDrug TherapeuticsHealth Technology/Digital HealthMedical DevicesMedical DiagnosticsResearch Tools/PlatformsSynthetic BiologyOther

At what stage of development is your company product/service (select one) * Pre-Concept StageConcept StagePrototype StageSaleable Product/Services StageOther

"Involvement to education" check all that apply:basic skills trainingmentor student projectsummer survey courseskills certificationcompany internshipjob/career faircollege and career awareness

Please provide a two-three sentence description of your company's technology: *

Describe how much funding the company has received, including the company's stage of funding (e.g., pre-seed, seed, A-round, etc.) and sources of funding (e.g. government, friends & family, etc.):) *

Describe the business activities planned for your company in the next 36 months: *

Please describe the unmet market need your product or services fulfills: *

Requirements

Approximate Space Requirements * Private lab space (up to 2 people)Private lab space (up to 8 people)Cubicle spaceShared Wet Lab Space

Desired Start Date of Occupancy: *

Estimated Length of Occupancy

List of equipment needs (e.g., biosafety cabinet, microscope, etc.): *

Please provide or attach any additional information (e.g., business plan, resumes of principals, etc.) that may help the review committee better understand your company, product, and/ or needs.

*Proof of Insurance, Workers Comp insurance, and a valid business license are required at the time of occupancy.

Max. file size: 20MB.