Innovation Fund Intake Form

Contact and Company Information

Company or Organization Name*

Representative Name*

Contact Email*

Contact Phone*

Website Link

Describe the goal of your company*

Do you currently have a Governing or Advisory Board?*

If yes, please upload a list of your Governing or Advisory Board members here

One file only.
2 MB limit.
Allowed types: gif, jpg, jpeg, png, txt, rtf, pdf, doc, docx, ppt, pptx, xls, xlsx.

Describe your current funding status*

Product Information

Describe your company’s product:*

What is the value proposition of your company’s product?*

Who are the end-users of your product? (transplant patient, dialysis patient, transplant surgeon, primary care doctor, dialysis provider, etc.)*

How will your product improve quality of life and quality of treatment for kidney patients?*

Which patient population(s) do you expect to benefit from your product?*

Describe your product's expected patient impact, both in terms of number of patients reached and degree of impact per patient:*

How long will this product take to develop and reach patients or consumers?*

Which category best describes your product?*

Describe your company’s leadership team and the experience and qualifications of its key members. You can provide this as an uploaded document or you can type it in:*

Upload Single Document

One file only.
20 MB limit.
Allowed types: gif, jpg, jpeg, png, txt, rtf, pdf, doc, docx, ppt, pptx.

Type in description

Describe your company’s current finances, including funds raised to date, burn rate, cash on hand, future fundraising rounds planned, etc. You can provide this as an uploaded document or you can type it in*

Upload Single Document

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20 MB limit.
Allowed types: gif, jpg, jpeg, png, txt, rtf, pdf, doc, docx, ppt, pptx.

Type in description

What regulatory challenges do you anticipate to secure FDA approval of your product, and how do you envision overcoming them?*

Summarize your company’s existing Intellectual Property:*

What else would you like us to know about your product or company?*

Other Materials

Please upload a document with any other materials you believe would be helpful in our evaluation (slide decks, executive summaries, etc.)

If you have multiple documents, please combine them in to one document before submitting. If you have a PowerPoint document, please save it as a PDF and submit.
One file only.
20 MB limit.
Allowed types: gif, jpg, jpeg, png, txt, rtf, pdf, doc, docx, xls, xlsx, bz2, dmg, gz, jar, rar, sit, tar, zip.

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