Pre-Conference of the 16th INS World Congress 11 May 2024

Innovations in Neuromodulation

Emerging Company Panel Application

Personal Information

Company Name*

Address - Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Country

Panelist's Full Name

Position with Company

Phone

Office Phone

Fax

Mobile or Home Phone*

Email

E-mail Address*

example@example.com

Company Information

Company Description*

Years in Existence

Company Website*

Product Information

Product Name

Product Description

Purpose

Product Development Stage

Major Investors

Clinical Trial Information (if applicable)

Official Title

Clinical Trial Registry (e.g. clinicaltrials.gov)

Registration Number

Study Start Date

Estimated Study Completion Date

Phase

Sponsors and Collaborators

Principal Investigator

For the opportunity of telling their story and showcasing their company to over 200 professionals in the neuromodulation field, each company selected to participate in the emerging company panels will be kindly requested to provide a $2,500 US unrestricted grant to the International Neuromodulation Society, a 501(c)3 nonprofit organization. These participating companies will also receive a two-meter table top exhibit in the session room for the duration of the day.

Grant Agreement*

By checking this box, I agree that if my company is selected to participate in
a panel, we shall provide a $2,500 US unrestricted educational grant to the INS.

If my company is selected, I would like to have a table top exhibit for this Innovations Day*

YesNo

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Yes, I have read and now acknowledge the linked INS Privacy Policy.No, I would like to withdraw my application.

Thank you!