Collaborative Funding Grant - NC Biotech



Collaborative Funding Grant

Company Background Form

Name of University/Non-Profit Applicant:      

Name of principal investigator at University/Non-Profit:      

Project title:      

To be eligible for CFG funding the non-profit/university applicant needs a company partner to make a matching cash contribution. Please list the name of the proposed matching company partner below and have the company provide the following information listed in Parts I through V. This information will be used to determine the company’s stage of development and to evaluate its ability to provide matching funds.

I. Company Executive Summary

Attach a Company Executive Summary (required).

II. Company Background and Business Plan

Company name:      

CEO/President:      

State of incorporation:      

Describe how the company has a significant presence in North Carolina (e.g. place of principal business operations; CEO resides in NC; NC is a regional headquarters; etc.):

     

Number of full-time employees:      

List name and company role of 5 most senior full-time employees:

1.      

2.      

3.      

4.      

5.      

Number of part-time employees:      

List name and company role of up to 5 part-time employees:

1.      

2.      

3.      

4.      

5.      

Company’s board of directors (list names of board members and their primary employers):

     

Company’s management (list) - Should include at least one employee who devotes at least 30 hours per week time towards company development/management as their primary focus. This employee must be a C-level executive and may not be the same person as the PI or scientific founder:

     

Company’s scientific advisory board (list names of board members and their primary employers):

     

Company’s growth projections (describe the company’s growth projections, i.e. employees, revenue):

     

Technology overview and scientific milestones of company (describe):

     

Company’s products and/or service offerings (describe):

     

Company’s market projections (describe):

     

Company’s development strategy and competitive advantage (describe, including a description of the company’s competition):

     

Company’s commercial strategy including revenue model, current sources, and projections for any funding needs along with potential targets (e.g. “need $500,000-$800,000, targeting local angel investor groups”):

     

Company’s exit strategy (describe):

     

III. Demonstration of Intellectual Property

Patent Number      or Filing Number      

(check one) This patent is owned by the company.

This patent is licensed by the company from      . Note the licensing agreement must be fully executed

Documentation is provided in this submission (required).

Please submit additional documentation as appropriate (e.g., copy of licensing agreement) as part of the Supplementary Confidential Business Information attachment. This information is for Center use only and will not be shared with outside reviewers.

IV. Statement of Commercial Strategic Importance

Please describe the value of the proposed project to the company’s commercial strategy and to the economic potential of North Carolina:

     

V. Current or Pending Grants

List any current or pending company grants, indicate how this project is distinct from other projects. (indicate None if not applicable).      

     

VI. Key Company Personnel Involved in Project

Please list the key company personnel involved in the project and include their CVs:

      CV Form included

      CV Form included

      CV Form included

      CV Form included

VII. Company CFG Matching Dollars

This form is accompanied by a statement, signed by the President or CEO of the company, which (1) verifies that the company has sufficient funds which it will contribute for the program in accordance with the following chart, and (2) commits the company to contribute financially to the program in accordance with the following chart:

|Company Contribution |

|1st year |$10,000 |

|2nd year |$10,000 |

|Total |$20,000 |

VIII. Financial Information

List sources of funding received in the last three years. Include private, institutional and federal grants, and other loans.

     

List future financial projections for the next five years

     

This form is accompanied by (1) an un-audited financial statement and/or (2) the company’s balance sheet from the company’s most recent quarter or a link to filed statement on annual report: provide link. (This information is for Center use only and will not be shared with outside reviewers.) Please submit as part of the Supplementary Confidential Business Information.

This Grant Application is subject to review and approval by the North Carolina Biotechnology Center in its sole discretion.

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