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Subject: LICENSE APPLICATION FORM Revision:
01		 Doc. No.
JLAB-LIC-1002
JANSSEN LABS
LICENSE APPLICATION FORM

Please submit NON-CONFIDENTIAL INFORMATON ONLY for consideration by Johnson & Johnson Pharmaceutical Research & Development, L.L.C. (J&JPRD) and its advisors, consultants and service providers in evaluating the application to license space at Janssen Labs.
 
GENERAL INFORMATION:
Business Name:
Key Company Representative(s) and Title:
Telephone:
Fax:
E-mail:
Website:
Current Business Address:
Address 1:
Address 2:
City:
State:
Zip:

COMPANY FORMATION:
Date Business Established:
Form of Ownership:
Industry Sector:
Nature of Business:
(brief description of product/service and nature of market)
Current Status of Business:
(e.g. working on prototype, product in advanced development)

FINANCIAL INFORMATION:
Amount & Type of Funding to Date:
Projected Funding Requirements/Date/Preferred Type:
Current Sales Revenue:
(please indicate dollar volume per month if applicable)
Projection of Sales Revenues in 12 Months
Projection of Sales Revenues at 24 Months
Monthly Burn Rate
Months of Operational Capital

PERSONNEL PROJECTIONS(FTES, PTES, CONTRACTORS, CONSULTANTS, ETC):
Start:
Projected Number of People Within 12 Months:
Projected Number of People Within 24 Months:

TYPE OF ACTIVITY & SPACE REQUIREMENTS:
Wet Lab Square Feet:
Dry Lab Square Feet:
Office Square Feet:
Other Requirements
   Biolab – Type of Equipment  
   Chemistry lab – Type of Equipment  
   Tissue Culture Rooms - Bacteria
   Tissue Culture Rooms - Virus
   Tissue Culture Rooms – Regular Cell Culture
   Equipment Room (Autoclave, Glass washer, -80, centrifuge, etc)
   Other Equipment  
Please attach PDF version of non-confidential information such as slide deck and/or executive summary with business plan and at a high level the target areas of research if applicable:
 

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Note: Maximum of 5 attachments and only accept word, powerpoint and pdf files with less than 2mb of file size.


Notice THE INFORMATION SUBMITTED BY APPLICANT HEREIN IS PROVIDED WITHOUT ANY OBLIGATION ON J&JPRD TO KEEP ANY SUCH INFORMATION CONFIDENTIAL AND WITHOUT PROHIBITION AGAINST ANY DISCLOSURE TOJ&JPRD'S AFFILIATES OR ADVISORS OR TO ANY THIRD PARTIES.