Application Form

Contact Information
Name of Organization*
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Website URL*
Primary Contact Person(s)
Name*
First Last
Email*
Enter Email Confirm Email
Phone*

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Media & Outreach
Please attach a still photo that will serve as the "face page" of your campaign. Photo resolutions and dimensions must be: 250x200 pixels @ 300 dpi.
Accepted file types: jpg, jpeg, gif, png, pdf, tif, bmp.
Campaign Video URL
Company Pitch Deck (PowerPoint or PDF)
Accepted file types: ppt, pptx, pptm, pdf.
Social Media Handles
Twitter
Facebook
LinkedIn
Instagram
Other

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Campaign Overview
Summary*
Please provide a summary that adequately describes your technology in layman's terms. Please limit to 30 words.
Fundraising Goal ($)*
Please enter an exact monetary value. Submissions without a clear fundraising goal will not be accepted.
Campaign Questions
Please limit each answer to 200 words. Please write your responses clearly, using non-technical jargon.
1. What is the critical gap in cancer treatment that you are addressing?*
2. What is the key product development milestone you seek to fund?*
3. How will funds be used? Please provide breakdown of major budget items.*
4-A. What key resources have/will you acquire to facilitate the accomplishment of the above product development milestone? (i.e. current funding sources, strategic partnerships, talent, infrastructure)*
4-B. If successful, how would you leverage funds raised through our portal to access key funding from other sources, (i.e. matching grants/investments).*
5. If your Technology were to disappear in the “Valley of Death” funding bottleneck how might this impact society?*

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Your Team
List your companies key human resources and provide a title and short bio of each.
Team Member 1
Team Member 2
Team Member 3
Team Member 4
Team Member 5
Team Member 6
Team Member 7
Team Member 8
Team Member 9
Team Member 10
Please click here to add additional team members if needed:

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Contact Information