PROPEL Awards for 2013 BIO Convention 1. COMPANY INFORMATION 25% of survey complete. Please complete this application for all grant options to attend the 2013 BIO Convention. This application deadline is February 25, 2013. The required attachments should be sent via email to PROPEL@ibioinstitute.org by the deadline of February 25, 2013. Question Title * 1. Please complete the following information for the company that you represent: Legal Company Name: * Company Address: Address 2: City: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP Code: Website: Phone Number: * Question Title * 2. Other company locations: Question Title * 3. Please complete the following information for the main contact of the company that you represent: Name: * Email: Phone Number: Question Title * 4. Please complete the following information for the authorized signatory of the company that you represent:(if it is the same as Q3, skip to Q5) Name: Email: Phone Number: Question Title * 5. Legal Entity Questions Date Legal Entity Formed: Type of Legal Entity: Federal Tax ID#: Question Title * 6. Company Category: Therapeutic/Pharma Medical Device Medical Diagnostic Combo (drug/device/diagnostic) Life Sciences Tools Ag-Industrial Biotech Other - explain below Other (please specify) Question Title * 7. Provide a company description:(no more than 100 words) Question Title * 8. Are you currently: Yes No An active PROPEL company? An active PROPEL company? Yes An active PROPEL company? No An active CIM mentee/venture? An active CIM mentee/venture? Yes An active CIM mentee/venture? No An active iBIO member? An active iBIO member? Yes An active iBIO member? No Working with another Illinois entrepreneurial organization? (if yes, explain) Working with another Illinois entrepreneurial organization? (if yes, explain) Yes Working with another Illinois entrepreneurial organization? (if yes, explain) No Comments Next