Henry Ford + MSU Innovation Hub Intake Form

INSTITUTION/COMPANY NAME

FIRST NAME

LAST NAME

TITLE/ROLE

PHONE

COUNTRY

PROVINCE/STATE

CITY/TOWNSHIP

ORGANIZATION TYPE

IF 'OTHER', PLEASE SPECIFY ORGANIZATION TYPE

INTEREST AREA(S), SELECT ALL THAT APPLY

IF 'OTHER', PLEASE SPECIFY INTEREST AREA

Collaboration Interests

WHAT TYPE OF COLLABORATION ARE YOU SEEKING

IF 'OTHER', PLEASE SPECIFY TYPE OF COLLABORATION YOU ARE SEEKING

ARE YOU CURRENTLY COLLABORATING WITH MSU OR HENRY FORD

ARE THERE SPECIFIC FACULTY, DEPARTMENTS, OR RESOURCES YOU WISH TO ENGAGE

IF 'OTHER', PLEASE SPECIFY TYPE OF ENGAGEMENT YOU ARE SEEKING

PROJECT TITLE (IF APPLICABLE)

SCIENTIFIC OR TECHNICAL AREA

IF 'OTHER', PLEASE SCIENTIFIC OR TECHNICAL AREA

INTELLECTUAL PROPERTY STATUS (IF APPLICABLE)

DO YOU HAVE FUNDING SECUED FOR THIS COLLABORATION

ANTICIPATED START DATE

DESIRED DURATION OF PROJECT/ENGAGEMENT

ARE YOU CURRENTLY UNDER ANY CONFIDENTIALITY AGREEMENTS (NDA) RELEVANT TO THIS COLLABORATION

WILL THIS COLLABORATION INVOLVE ANY OF THE FOLLOWING

LEGAL/TECHNOLOGY CONTROLS