Baxter Ventures - Application for Funding

Please do not include confidential information. Baxter will not sign a Non-Disclosure Agreement (“NDA”) for any initial discussions or submissions. If there is sufficient interest by Baxter, an NDA may be signed at a later date.

Company Name:
Company Address:
Phone Number:
Website/URL:

# of Employees:

Key Contact:
Contact E-mail Address:
Contact Phone Number:
Date Founded:
Total $ Funding Raised:
Please provide the name of any individual or group at Baxter with whom you are or have been in correspondence regarding your company or technology. If you have not been in contact with any individual or group at Baxter, please indicate “None”.
(1,500 character limit; approximately 300 words per each category below.) Company Information. Please provide a brief history of the company, funding raised to-date/sources and current stage of development:

Product/Technology. Please identify the unmet clinical need that you are solving and a summary description of your solution/offering:

Market Opportunity. Describe the current market size and geographies, market dynamics, addressable patient population, relevant physician targets, pharmacoeconomic benefits and revenue potential:

Technical/Clinical Development Pathway. Describe the intended development pathway including clinical trials, regulatory assumptions and timeline to market:

Management Team. Identify key members of the management team and relevant experience:

Investment/Strategic Resources Requested. Describe the amount of funding being sought, the investment round, the technical and/or commercial milestones to be achieved with this investment and any strategic resources being sought:

BY CHECKING THIS BOX, COMPLETING NAME, DATE, COMPANY BELOW AND SUBMITTING THIS PROPOSAL AND ANY SUPPORTING INFORMATION TO BAXTER, YOU HEREBY AGREE TO THE FOLLOWING: This submission and all materials delivered along with this submission are non-confidential in nature. You understand and agree that Baxter will (a) not treat this information as confidential or proprietary, (b) not be restricted from using such information or disclosing such information to third parties, and (c) have no liability to you or any third party for use or disclosure of such information. Baxter is not obligated to pursue an opportunity with you, or to reply to your submission. Any decision to pursue an opportunity with you will be made by Baxter in its sole discretion. I have read and agree to the foregoing:
Company:
Name:
Title:
Date:
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