SBIR/STTR Assessment Form Before you submit your Assessment Form, we strongly suggest that you watch our free webinar “ABC’s of SBIR/STTR .” Once the form is received, one of our consultants will schedule a call with you to answer your questions, determine your current status and discuss how we can best help you. There is no charge for this call. The info provided in the webinar together with your Assessment Form make for a more productive and useful call. Name* First Last Preferred Email* Phone*Company/organization name (if not formed put "none")*What is your title within the company? (i.e., President, Founder, CEO, CSO, etc.)*Is your Company*Women OwnedVeteran OwnedAfrican American OwnedAmerican Indians ownedOwned by Alaska Natives, Hispanics or Asians and Pacific IslandersProject Principal Investigator is a member of one of these groupsNone of the abovePrefer not to answerIn what year was the company formed? (if not formed put "none")*If formed, is your company an S-Corp, C-Corp, LLC or OtherS-CorpC-corpLLCOtherIf "other", please explain:Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code If your company has a website, please enter the URLWere you referred to BBCetc by another organization? If so, please provide the organization's name:*Eligibility RequirementsDoes your company fulfill the following SBIR/STTR eligibility requirements?Does your company have less than 500 employees?*YesNoIs the majority of the company (>51%) owned by individuals?*YesNoIf yes, are they US Citizens/Permanent Residents?YesNoDoes the company have any institutional, corporate and/or non-US owners?*YesNoDo you have company-controlled R&D space?*YesNoIf no, have you identified space that you will move into at the time of award?YesNoIf yes, please describe the company facilities and identify their location:Have you identified a Principal Investigator (PI) who will be 51% employed by the company at the time of award?*YesNoWe plan to do an STTR and have identified a PI at a collaborating institutionBriefly describe the background and qualifications of the PI:*Tell us about your SBIR/STTR ProjectPlease answer the following questions that relate to your SBIR/STTR project and related technology/product:To which Federal Agency(ies) do you plan to apply?* National Institutes of Health (NIH) National Science Foundation Dept. of Defense (DoD) Dept. of Energy (DoE) U.S. Dept of Agriculture (USDA) Another Agency Don't know yet If you answered "another agency" above, to which agency do you plan to apply?What submission deadline are you targeting?*Briefly describe the product to be developed:*Please check all of the following that apply to your technology?* Patent application submitted Patent issued We have trade secrets or other intellectual property (IP) N/A What is the ownership status of your IP?*My company owns the IPA university or other entity owns the IPN/ABriefly describe the "technological innovation" to be implemented in the product?*Who is the intended customer for your product?*Briefly describe your commercialization strategy?*Previous SBIR experienceHave you ever applied for SBIR/STTR before?*YesNoHave you received any SBIR/STTR awards?*YesNoBriefly describe any previous/current SBIR/STTR awards:How would you describe your proposal-writing experience?*No previous proposal-writing experienceI've helped people write proposalsI've written proposals before but not SBIR/STTRsI've written unsuccessful SBIR/STTRsI've written successful SBIR/STTRsHave you attended any SBIR/STTR training? If so, please describe briefly.*Is there anything else you would like to add?Captcha SBIR/STTRSolicitation Dates Registration Requirements Helpful Links SBIR/STTR FAQ Join Our Mailing List
