M2D2 Office Hours Request Form

First Name

Last Name

Email Address

Phone

Company

Address

City

State

Zip

Which office hours host would you like to meet with?

Are you university-based or company-based?

University

Business

Disease space (max 5 words)

Description of technology (max 200 words)

Need or support requested (max 200 words)

Stage of development (Choose all that apply)

Proof of concept

Working prototype

Pre-clinical

Clinical

Status of IP

Provisional patent(s)

Issued patent(s)

Utility patent(s)

Licenses

Other

Use this space to further explain status of intellectual property, including potential infringements and/or other related information (200 words max)

Attachment option for non-confidential executive summary, slide deck, video, etc. (Max 3)

*Required fields

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