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2020 VIP Forum Application
Thank you for your interest in applying for a one-on-one meeting during our upcoming Venture Investment & Partnering (VIP) Forum!
Name
First
Last
Professional Title
*
Phone
Email Address
*
Company Name
*
Company Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
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Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
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Eswatini
Ethiopia
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Finland
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French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
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Guadeloupe
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Guinea-Bissau
Guyana
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Holy See
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Hungary
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India
Indonesia
Iran
Iraq
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Isle of Man
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Japan
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Jordan
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Kenya
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Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
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Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
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Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
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Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
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Tonga
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Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
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Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Website
Year of company incorporation
Number of Employees
Management Team and Board
*
Subsector
*
BioPharma
Medical Technology
Digital Health/Health IT
Global Health
Research Institute
Other (please explain)
If you selected Other, please explain
Technology Classification (select all that apply)
*
Medical Device
Diagnostic
Software
Therapeutic
Platform Technology
Other (please explain below)
If you selected other, please explain:
Area(s) of Focus
*
Oncology
Metabolic
Neuroscience
Vaccine
Immunotherapy
Immunology
Infectious Disease
Cardiovascular
Addiction
Consumer
Genomics
Personalized Medicine
Rare & Orphan Diseases
Reproductive Health
Other (please explain below)
If you selected other, please explain:
Brief description of your technology/research:
*
Development Stage
*
Approved
IND
NDA
Phase I
Phase II
Phase III
Pre-Clinical
Other (explain below)
If you selected other, please explain:
Key partnership objectives:
*
Brief description of recent milestones and next steps:
*
Current partnerships or alliances:
*
Are you generating revenue?
*
Yes
No
Capital raised to date and funding history:
Amount of capital sought and milestones to be achieved on that capital:
*
Status of intellectual property:
*
License executed
License pending
Utility patent issued
Utility patent pending
Provisional patent filed
Unknown
Other (please explain)
Δ
About Us
About LSWI
Our Team & Board
FAQ’s
Life Science Washington
News
Programs
Programs Overview
Gala
DRIVe Accelerator
DRIVe Webinar
Lunch & Learn Series
Start-Up Assistance
SBIR/STTR
Virtual Grant Writing Workshop
WIN Mentoring
VIP Forums
Career Development Workshop
World IP Day 2023
Events
Get Involved
Playbook
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