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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
(Required.)
Name
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Company
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Address
Address 2
City/Town
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State/Province
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ZIP/Postal Code
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Email Address
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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)
3.
Brief Description of innovation or business
4.
Has your company successfully raised capital? Includes dilutive and non-dilutive sources
Yes
No
Unsure
If yes, how much?
5.
Source of company IP?
Created In-house
Licensed
Combination of in-house and licensed IP
No IP
If licensed, from where?
6.
Are you actively fundraising?
Yes
No
7.
Stage of company
idea
proof-of-concept
series A
market ready
generating revenue
Other (please specify)
8.
Please identify a few issues that you would like to cover during your visit
9.
Are you interested in applying for our Washington Innovation Network (WIN) Mentoring program?
Yes
No
I don't know: tell me more
10.
How did you hear about our startup assistance consulting?
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11.
Race, Ethnicity (based on census data)
(Required.)
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)
(Required.)
Yes
No
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)
(Required.)
Yes
No
Not Sure
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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)
(Required.)
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15.
Enter HQ Zipcode
(Required.)
Current Progress,
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