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First name

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* 1. First name

Last name

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* 2. Last name

Email address

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* 3. Email address

Phone number

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* 4. Phone number

City/town

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* 5. City/town

State/province

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* 6. State/province

From what institution, in what state, did you graduate?

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* 7. From what institution, in what state, did you graduate?

Which of the following best describes your primary affiliation over the past year?

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* 8. Which of the following best describes your primary affiliation over the past year?

What are your primary areas of technical expertise? (Please select all that apply.)

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* 9. What are your primary areas of technical expertise? (Please select all that apply.)

What are your secondary areas of technical expertise? (Select up to two areas.)

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* 10. What are your secondary areas of technical expertise? (Select up to two areas.)

What is the title of your technology?
This title should describe technology you intend to propose for CRI, not your personal professional title.

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* 11. What is the title of your technology?
This title should describe technology you intend to propose for CRI, not your personal professional title.

What is your primary technology focus area? (For more information please see the DOE Advanced Manufacturing Office’s Multi-Year Program Plan.)

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* 12. What is your primary technology focus area? (For more information please see the DOE Advanced Manufacturing Office’s Multi-Year Program Plan.)

What is the industry sector of the proposed technology (Select all that apply.)

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* 13. What is the industry sector of the proposed technology (Select all that apply.)

What key words are associated with your technology?
Use commas to separate.

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* 14. What key words are associated with your technology?
Use commas to separate.

Has this project received outside funding? (Select all that apply.)

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* 15. Has this project received outside funding? (Select all that apply.)

How did you hear about Chain Reaction Innovations? (Select all that apply.)

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* 16. How did you hear about Chain Reaction Innovations? (Select all that apply.)

If applicable, who referred you?

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* 17. If applicable, who referred you?

Have you previously applied to one of the Lab-Embedded Entrepreneurship Programs? (Select all that apply.)

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* 18. Have you previously applied to one of the Lab-Embedded Entrepreneurship Programs? (Select all that apply.)

Did you attend a prospective applicant webinar prior to the application period? (Check all that apply.)

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* 19. Did you attend a prospective applicant webinar prior to the application period? (Check all that apply.)

Personal and Company Twitter Handles

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* 20. Personal and Company Twitter Handles

Link to company website, if available

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* 21. Link to company website, if available

In what state did you originally launch your start-up in?

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* 22. In what state did you originally launch your start-up in?

Will you have raised more than $1M in private funding at the time of entry into the CRI program?

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* 23. Will you have raised more than $1M in private funding at the time of entry into the CRI program?

Are you a first-time founder?

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* 24. Are you a first-time founder?

Are you a U.S. citizen or permanent resident?

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* 25. Are you a U.S. citizen or permanent resident?

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