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). OK Question Title * 1. Company Information Name * Company * Address Address 2 City/Town * State/Province * ZIP/Postal Code * Email Address * Phone Number * OK Question Title * 2. Company/Organization Category BioPharma (Biotech/Pharmaceutical) Medical Technology (Device/Diagnostic) Digital Health/Health IT Global Health Other (please specify) OK Question Title * 3. Brief Description of innovation or business OK Question Title * 4. Has your company successfully raised capital? Includes dilutive and non-dilutive sources Yes No Unsure If yes, how much? OK Question Title * 5. Source of company IP? Created In-house Licensed Combination of in-house and licensed IP No IP If licensed, from where? OK Question Title * 6. Are you actively fundraising? Yes No OK Question Title * 7. Stage of company idea proof-of-concept series A market ready generating revenue Other (please specify) OK Question Title * 8. Please identify a few issues that you would like to cover during your visit OK Question Title * 9. Are you interested in applying for our Washington Innovation Network (WIN) Mentoring program? Yes No I don't know: tell me more OK Question Title * 10. How did you hear about our startup assistance consulting? OK Question Title * 11. Race, Ethnicity (based on census data) 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 OK Question Title * 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) Yes No Not Sure OK Question Title * 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) Yes No Not Sure OK Question Title * 14. Headquarter Location (As registered with the WA Secretary of State Corporations and Charities Filing Database (Ref. https://ccfs.sos.wa.gov) OK Question Title * 15. Enter HQ Zipcode OK DONE