APPLICATION FORM

PRINCIPAL INVESTIGATOR & ACADEMIC TITLE*

INSTITUTION & DEPARTMENT*

EMAIL*

INSTITUTIONAL / DEPARTMENTAL ADMINISTRATOR NAME & EMAIL*

CO-INVESTIGATOR(S)*

Only include those investigators who will be funded under the proposed Extend scope of work.

CO-INVESTIGATOR(S) AFFILIATION(S)*

If you are planning on involving Investigators external to the Institution please discuss first with the Extend EIR or your local Extend contact

CO-INVESTIGATOR(S) EMAIL(S)*

TECHNOLOGY TRANSFER OFFICE MANAGER & EMAIL*

INSTITUTION PROJECT NUMBER*

If your project does not already have a project number please ask your local TTO to create one.

PROJECT INFORMATION

PROJECT TITLE*

Indicative of research field and uniqueness of approach.

EXECUTIVE SUMMARY*

Outline of scientific rationale, therapeutic relevance and proposed goals of the project including planned start date and duration. Please provide a summary of the total budget extracted from the project plan below (max 300 words).

INTRODUCTION*

Summary of background to the proposed research including previous own work and any supporting evidence from third parties (max 1000 words). Please detail the current status of the project and any relevant publications.

THERAPEUTIC INDICATION & MEDICAL NEED*

Brief description of therapeutic problem(s) to be solved and target indication(s) or disease envisaged should the results of a Extend award give rise to a product. (max 300 words)

COMPETITIVE APPROACHES & MARKET POTENTIAL

Brief overview of competition in the envisaged therapeutic space and the potential size of the market to the degree applicable, e.g. how is your approach different to what is currently being used/in development and what is the size of the applicable patient population. Also any secondary indications should be listed. Any routes to patient stratification and potential biomarkers associated with the target hypothesis should be included (max 500 words).

ANTICIPATED FOREGROUND IP

Based on the envisaged work plan and described background IP, please provide a summary of the expected deliverables at completion of the funding. Examples include a number of chemical starting points or an antibody with a desired biological effect either in vitro or in vivo, new lines, reagents, new data, know how, methods, models, and techniques.

BACKGROUND IP & THIRD-PARTY FUNDING

Please answer the following questions which are for the purposes of internal academic institution diligence. (Please note that having an existing patent application is not a pre-requisite for a successful Extend application):

1. Has the project proposal above been subject to local TTO support and review throughout?
2. Is there any relevant Institution/University background IP required to perform the work under the Extend application? [Background IP is IP that exists before the project begins, and includes patented IP, know-how, data, materials e.g. mouse models or reagents]. Has an invention disclosure form been submitted or is this imminent? Please work with the respective TTO to provide a list background IP and ancillary IP used to perform any of the institution/university work packages.
3. If background IP exists (and it is not an existing Institution/University project) what grants or funding awards supported its creation?
4. Are there any reach through claims to future foreground IP and/ or commercialization rights imposed by any such funding bodies?
5. Are you aware of any external Background IP that may be needed to carry out the project for example a mouse model sourced from a third party, or any material under an MTA? [Where possible applications will ideally avoid use of any IP subject to third party rights to avoid the need to negotiate consents which may not always be possible/feasible].
6. Do you have any conflicts of interest that may need to be managed e.g. a consultancy advising on a competing program of work?

(Where there is an existing Institution/University project with a filed patent please summarize the status of the patent and its relationship to the anticipated arising IP under the Extend award.)
If you have any questions please contact your existing tech transfer department manager.

EXTEND WORK PLAN

Please provide a description of the individual work packages for the proposed project and where the work is expected to be performed.

Please include all significant reagent costs within the table. Also highlight any relevant third party license fees associated with the use of a particular technology or reagent and indicate where a MTA may be required to perform the work (e.g. particular cell lines).

RISK ASSESSMENT

Brief assessment of main technical risk(s) for the proposed project and how they will be addressed.

NEXT STEPS

If the project milestones are achieved what are the next technical (e.g. lead optimization, preclinical studies) and funding (e.g. apply for another Extend award, spin-out or alternative translational funds?) activities (max 300 words).