ICIP / MA-Non US
Dec 12, 2012
International Collaborative Industry Program
Partner Interest Form
1. Company Details
1.1 Organization Name
Full Name
Parent Organization
Legal Structure
Corporation
Limited Liability company
Sole proprietorship
Partnership
other
1.2 Organization Address
Street
Zip or Postal Code
State
City
Country
1.3 Contact Person Data
Name
Function
Direct phone Number
and Mobile Number
E-mail
1.4. Website
1.5 Organization Background
Year Established
No. of R&D
Personnel
No. of Employees
Seed
Development
Clinical
Stage
Revenue Generation
other
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ICIP / MA-Non US
Dec 12, 2012
Core Business &
Area of Expertise
Main Products /
Services
Comments
2. The Project
2.1 Main Technological Area
2.2 Clinical Application
2.3 Description of the proposed joint commercially focused R&D project
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ICIP / MA-Non US
Dec 12, 2012
3. Potential Partner/Company
3.1 Specific R & D contribution and/or technologic expertise you are seeking
(For example: specific wavelength of laser)
3.2 Other characteristics you are seeking in partner (For example: market
participation, clinical affiliations)
3.3 Companies or organizations with whom you are already in contact
I hereby provide my consent to disclose this form to third parties in the process
of identifying potential partners for the proposed project
Last
Name
Signature
First
Name
Date
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