Otsuka VIP Forum Application
1:1 Sessions will be held with representatives from Otsuka on March 16th. LSWI will reach out to you by March 3rd if you are selected for a meeting.
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1.
First and Last Name
(Required.)
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2.
Professional Title
(Required.)
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3.
Phone
(Required.)
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4.
Email Address
(Required.)
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5.
Company name
(Required.)
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6.
Street address
(Required.)
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7.
City
(Required.)
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8.
State
(Required.)
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9.
Website
(Required.)
10.
Year incorporation/ formation
11.
Number of employees
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12.
Subsector (select one)
(Required.)
Biotech
Medtech
Digital Health/Health IT
Global Health
Research Institute
None of the above
Other (please specify)
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13.
Technology Classification (select all that apply)
(Required.)
Medical Device
Diagnostic
Platform Technology
Therapeutic
Software
Other (please specify)
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14.
Area of focus (select all that apply)
(Required.)
Psychiatry
Neurology
Nephrology
Immunology
Digital
Other (please specify)
15.
Management team and Board (200 word max)
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16.
Target / Underlying Biology / MOA / Modality
(Required.)
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17.
Disease area(s) / Disease(s) targeted
(Required.)
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18.
Description of your technology (200 word max)
(Required.)
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19.
Development Stage
(Required.)
Pre-Clinical
IND
Phase I
Phase II
Phase III
Approved
NDA
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20.
Key partnership objectives (200 word max)
(Required.)
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21.
Current partnerships and/or alliances (200 word max)
(Required.)
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22.
Key next steps in development
(Required.)
23.
Are you generating revenue?
Yes
No
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24.
Recent milestones and next steps (200 word max)
(Required.)
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25.
Status of Intellectual Property
(Required.)
License pending
License executed
Provisional patent filed
Patent pending
Patent issued
PCT application filed
Other (please specify)
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26.
Ownership
(Required.)
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27.
Capital raised to date and funding history
(Required.)
