Start-up Assistance Consulting Request Form

Thank you for your interest in the Life Science Washington Institute Start-up Assistance Consulting Program and WIN Mentoring Program. Please direct any questions to Aylin Kim (aylin@lswinstitute.org).

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* 1. Company Information

Name *

Company *

Address

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 2. Company/Organization Category

BioPharma (Biotech/Pharmaceutical)

Medical Technology (Device/Diagnostic)

Digital Health/Health IT

Global Health

Other (please specify)

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* 3. Brief Description of innovation or business

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* 4. Has your company successfully raised capital? Includes dilutive and non-dilutive sources

Yes

Unsure

If yes, how much?

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* 5. Source of company IP?

Created In-house

Licensed

Combination of in-house and licensed IP

No IP

If licensed, from where?

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* 6. Are you actively fundraising?

Yes

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* 7. Stage of company

idea

proof-of-concept

series A

market ready

generating revenue

Other (please specify)

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* 8. Please identify a few issues that you would like to cover during your visit

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* 9. Are you interested in applying for our Washington Innovation Network (WIN) Mentoring program?

Yes

I don't know: tell me more

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* 10. How did you hear about our startup assistance consulting?

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* 11. Race, Ethnicity (based on census data)

Hispanic.

White alone, non-Hispanic.

Black or African American alone, non-Hispanic.

American Indian and Alaska Native alone, non-Hispanic.

Asian alone, non-Hispanic.

Native Hawaiian and Other Pacific Islander alone, non-Hispanic.

Some Other Race alone, non-Hispanic.

Prefer not to disclose

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* 12. Socially or economically disadvantaged (Using the small business administration definition found here: https://www.sba.gov/federal-contracting/contracting-assistance-programs/8a-business-development-program#id-program-qualifications)

Yes

Not Sure

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* 13. Company More than 50% Women owned (as defined and certified by the SBA definition found here: https://www.sba.gov/federal-contracting/contracting-assistance-programs/women-owned-small-business-federal-contract-program#id-program-eligibility-requirements with link to certification)

Yes

Not Sure

Start-up Assistance Consulting Request Form

Question Title

* 1. Company Information

Question Title

* 2. Company/Organization Category

Question Title

* 3. Brief Description of innovation or business

Question Title

* 4. Has your company successfully raised capital? Includes dilutive and non-dilutive sources

Question Title

* 5. Source of company IP?

Question Title

* 6. Are you actively fundraising?

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* 7. Stage of company

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* 8. Please identify a few issues that you would like to cover during your visit

Question Title

* 9. Are you interested in applying for our Washington Innovation Network (WIN) Mentoring program?

Question Title

* 10. How did you hear about our startup assistance consulting?

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* 11. Race, Ethnicity (based on census data)

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* 12. Socially or economically disadvantaged (Using the small business administration definition found here: https://www.sba.gov/federal-contracting/contracting-assistance-programs/8a-business-development-program#id-program-qualifications)

Question Title

* 13. Company More than 50% Women owned (as defined and certified by the SBA definition found here: https://www.sba.gov/federal-contracting/contracting-assistance-programs/women-owned-small-business-federal-contract-program#id-program-eligibility-requirements with link to certification)

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* 14. Headquarter Location (As registered with the WA Secretary of State Corporations and Charities Filing Database (Ref. https://ccfs.sos.wa.gov)

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* 15. Enter HQ Zipcode