PLSA/LifeX Startup Intake Form
Please complete this form if you are a startup or entrepreneur interested in engaging with the PLSA/LifeX team, participating in community events and other opportunities.
Company Information
Company Name
*
Brief Company Description
*
0/50
Industry Vertical
*
Therapeutics & Drug Development
Diagnostics & Genomics
Medical Devices
Digital Health & Health IT
Technology-Enabled Healthcare Delivery & Clinical Infrastructure
Life Sciences Tools & Research Platforms
Contract Development & Manufacturing (CDMO)
Specialty Pharmacy & Patient Services
Other
ctrl+ select to choose multiple
Company Website
Optional
Company LinkedIn Profile
Optional
Company HQ Location
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Information
Primary Contact Name
*
First Name
Last Name
Primary Contact Role
*
CEO, Founder, etc.
Primary Contact Email
*
example@example.com
Primary Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Contact LinkedIn
Optional
What is your primary interest in connecting with PLSA/LifeX?
*
Additional Company Information
Is the company a university spinout or have other direct ties to a particular university?
*
Carnegie Mellon University
University of Pittsburgh
University of Pennsylvania
Penn State University
Temple University
West Virginia University
University of Maryland
No university affiliation
Other
If University Association is "other", please specify:
Year Founded In:
Leadership team members & Roles:
Please list and comment on the capacity and commitment of each team member. Are they in an active contributor role or advisory role? Are they currently full-time, or do they intend to join the company full-time in the future?
0/200
Company Stage:
e.g., idea, pre-seed, seed, early-stage, growth, or commercialization
What is your current revenue and funding status?
0/200
Has your company received any grants (e.g., SBIR/STTR, ARPA-H, NIH)?
0/200
Who are your key partners, collaborators, and funders?
0/200
What products, technologies, or solutions are currently in your pipeline, and what is their development status?
0/200
What therapeutic areas, disease indications, or healthcare markets does your company target?
0/200
What are your company's most immediate needs, priorities, or challenges? Where would additional support, resources, or connections be most valuable?
Please specify the individual or organization who referred you:
Supplemental Documents / Attachments
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To supplement your application, feel free to upload an executive summary, presentation/pitch deck, or paper here.
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