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). OK Question Title * 1. Company Information Name * Company * Address Address 2 City/Town * State/Province * ZIP/Postal Code * Email Address * Phone Number * OK Question Title * 2. Company/Organization Category BioPharma (Biotech/Pharmaceutical) Medical Technology (Device/Diagnostic) Digital Health/Health IT Global Health Other (please specify) OK Question Title * 3. Brief Description of innovation or business OK Question Title * 4. Has your company successfully raised capital? Includes dilutive and non-dilutive sources Yes No Unsure If yes, how much? OK Question Title * 5. Source of company IP? Created In-house Licensed Combination of in-house and licensed IP No IP If licensed, from where? OK Question Title * 6. Are you actively fundraising? Yes No OK Question Title * 7. Stage of company idea proof-of-concept series A market ready generating revenue Other (please specify) OK Question Title * 8. Please identify a few issues that you would like to cover during your visit OK Question Title * 9. Are you interested in applying for our Washington Innovation Network (WIN) Mentoring program? Yes No I don't know: tell me more OK Question Title * 10. How did you hear about our startup assistance consulting? OK DONE