Application Form

Name of Company: Company Contact:
Address 1: Email Address:
Address 2: Phone Number:
City: Fax Number:
State: Web Address
(if available):
Zip Month/Year Founded:
Sector (e.g., therapeutics, diagnostics, devices, etc.):
Company Stage (concept, start-up, pre-seed, etc.):
Management Team (names, titles, previous positions held, role(s) in company):
Number of Employees:
Corporate Counsel:
Patent Counsel:
Accounting Firm:

FINANCIAL INFORMATION

Current Financing
Near-term Financing Plans (friends/family, grants, angel, VC):
Amount of Financing Sought and Use of Proceeds:
Financial Results and Projections(Indicate current and projected results if possible):
Current – Year 1 - Year 2 - Year 3

COMPANY INFORMATION

Business Description:
Company Background (Provide any background information regarding the company):
Technology (current programs and/or products in development):
Intellectual Property Rights (list titles of patents and applications, provisionals, describe any in-licensed or out-licensed technology):
Has a business plan been written?
SBIR or other grants received/applied for?
Customers and Markets(provide an overview of your marketing activities (current or future products or services), and a description of your target customers):
Competition/Barriers to Entry (describe major competitors and any barriers that may restrict your company or new competitors from easily entering your market):
Positioning/Differentiation (describe how the company positions itself within its market sector and the major attributes that differentiate the company from its competition):
Exit Strategy (the company’s long-term strategy and time-frame—organic growth, merger/acquisition, IPO, etc.):
What type of assistance are you seeking?:

SUPPORTING DOCUMENTS

You may also submit additional information that will help the Diligence panel better understand your business, stage of development, financial needs, technology and the types of services we can provide to your company.

Suggested non-confidential documents that may supplement this application include an Executive Summary, Company Overview, published patents or applications, business presentation, or technical presentation.

QUESTIONS? PROBLEMS?

Please contact kiz@pco.edu for more information or call 215.780.1532.

Please print out this form and mail it to the address below:

BioLaunch611+ KIZ
8360 Old York Road
Elkins Park, PA 19027

Or click this button to submit it to kiz@pco.edu
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