Name*

Email Address*

Please describe yourself*

Northwestern Startup (startup with an active option or license with the university)

Northwestern Faculty with startup interest

Company Name

Year of Incorporation

Funding Raised to Date

Name of Founding PI(s)

Source of Funding

Number of FTEs

Desired Space Type (check all that apply)

Wet Lab

Dry Lab

Private Office

Shared Workspace

Describe Lab Needs (Size, # Benches, # of Hoods, etc.)

Anticipated Lab Needs

Biological Safety

Animal Work

Hazardous Chemicals

Compressed Gas

Controlled Substances

Cryogenic Liquids

Radioactive Materials and/or Radiation-Producing Machines

Desired Time Frame

As soon as possible

3-6 months

6-12 months

Please provide a one sentence description of the technology.

Please list any questions you have.

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