PROGRAM APPLICATION SECTION I: GENERAL INFORMATION Company Name: Head Office Address: Head Office Telephone: Company Website URL: Main Contact Name & Title: Main Contact Address (if different from above): Main Contact Telephone: Main Contact Email: Company Twitter Handle: @ Other Relevant URL: Is your company a YES If yes, complete sections I, II and V only. Enterprise (MNE) or NO a MaRS Venture Client? If no, complete all sections. SECTION II: TECHNOLOGY 1. Proposed Name of Technology: 2. Describe the problem the technology aims to solve. Provide a brief description of the health claim(s) of the technology, and the potential value the 3. technology could deliver to patients, clinicians and health systems. What is the primary target patient population (gender, age, medical condition(s), care setting, 4. stratification, etc.)? Describe.
PROGRAM APPLICATION SECTION I: GENERAL INFORMATION Company Name: Head Office Address: Head Office Telephone: Company Website URL: Main Contact Name & Title: Main Contact Address (if different from above): Main Contact Telephone: Main Contact Email: Company Twitter Handle: @ Other Relevant URL: Is your company a Enterprise (MNE) or a MaRS Venture Client? YES If yes, complete sections I, II and V only. NO If no, complete all sections. SECTION II: TECHNOLOGY 1. Proposed Name of Technology: 2. Describe the problem the technology aims to solve. 3. Provide a brief description of the health claim(s) of the technology, and the potential value the technology could deliver to patients, clinicians and health systems. 4. What is the primary target patient population (gender, age, medical condition(s), care setting, stratification, etc.)? Describe.
2016.11.24-EXCITE-Program-Application-Form-Version-2.0.docx