Mentoring, Assessment and Planning (MAP) Program Intake Form
Please enter your name.
What is your preferred email address to receive our email communications?
What is your work phone number?
If affiliated with an academic research institution, select from the following list:
University of Kansas Medical Center
University of Nebraska Medical Center
University of North Dakota
University of Oklahoma
University of South Dakota
If "other," please provide the name of the academic institution with which you are affiliated and the state in which it is located:
What is your role at the university?
Postdoc / Fellow
What is your company's name? (If not formed put "none")
What is your role within the company?
Company preferred mailing address (if not formed provide your preferred mailing address)
What is your company website address? If you do not have a website please leave blank.
Is your company or would your company be?
Native-American/Alaskan Native/Pacific Islander Owned
None of the above
Prefer not to answer
What is the legal structure of your business?
Limited Liability Company (LLC)
Not formed yet
If "other", please explain:
If you are in business, in what month and year did your business start? (enter in MM/YYYY format) If you have not formed a company yet, leave blank.
How did you hear about the SHARPhub Program?
About your Business and Innovation
Problem (describe the problem/opportunity your technology is intended to address)
Solution (how does your technology address the users’ problem and how is that solution differentiated from others competing in this space)
Size of Opportunity (identify the target market, its size, and recent trends in dollars, units sold, or the number of users):
Business Model (complete the business model canvas, available from seminar materials with hypotheses for each component). Note whether any validating research has been conducted.
Management Team (briefly identify team members and qualifications for pursuing development of this technology):
Current Development Status (describe technology development efforts/results to date):
Key developmental needs as your foresee them: