Professional/Company Application Step 1 of 4 - Contact Information0%1. Applicant Contact InformationThank you for your interest in applying to The Fogarty Innovation. Please complete the following form, which is intended to provide us with a summary overview of your company and team. Provide sufficient detail to convey the important elements of your project, but please also be concise. Most questions can be answered in one or two paragraphs. Note that any information you provide may be distributed within the Fogarty Innovation and to select external advisors who will be assisting in the applicant review process. Therefore, do not include any sensitive or confidential information in the materials you submit. Once you have completed the following form along with a current resume/CV for each of your team members. You may also include a non-confidential pitch deck or overview presentation.Contact Name First Last Email PhoneCompany NameAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Website Address 2. The Ideaa. What unmet need does your innovation seek to address?b. Provide a concise description of your product / services and how it addresses the target unmet need. Be sure to include the key advantages it offers over existing products / services.c. Describe the development stage of your innovation (e.g. prototype, preclinical testing, etc.) and summarize any evidence supporting its proof of concept.d. What is the estimated market size / potential for your innovation?e. What is the initial target market (customer & geography) for your innovation?3. The Development Plana. Summarize the key product development and business activities you would plan to undertake while at the Fogarty Innovation to make your company ready for Series A investment.b. What type of facility support would you need from the Fogarty Innovation?c. What type(s) of mentoring support would you seek from the Fogarty Innovation?d. How has your project been funded to date? Provide a general sense of the amount raised and its source (e.g. grants, angels, “friends & family”)?4. The Teama. Please provide the following information for each of your team members:NameTitle/RoleFull/Part Time?Local?* (Y/N) * I.e. Is person local and able to maintain working hours at the Fogarty Innovation?b. Summarize any additional key advisors/consultants involved with the project.c. Summarize any special experience or characteristics your team has that you believe will increase your likelihood of being successful entrepreneurs?Resume(s) and/or attachments Drop files here or Select filesMax. file size: 5 MB.