Information Submission Form

Licensed Start-up Company (LSC) Information Submission Form for review by Conflict of Interest Committee (COIC) (Please TYPE all information.)

COMPANY NAME: COMPANY MAILING ADDRESS CEO NAME: CEO PHONE NUMBER: CEO E-MAIL ADDRESS: DATE OF SUBMISSION:

1. EQUITY INTERESTS OF UNIVERSITY EMPLOYEES/STUDENTS & FAMILY MEMBERS Provide full name, department affiliation, email and phone number of all University faculty, staff and students and members of their immediate families (i.e., spouses, registered domestic partners, dependents, and/or any other members of their households) who will have an equity interest (including stock options or warrants) in the company.

If the total amount of requested equity to be held in the company by the University and/or its faculty, staff, students and/or members of their immediate families will exceed 49%, please contact the COI Office in advance of submitting this form. Please note that this request takes additional time to process and should be submitted to the COI Office no less than two weeks prior to the COI Committee meeting at which this submission will be considered. The dates of the COI Committee’s meetings can be found at http://www.coi.pitt.edu/Committee/CommitteeMtngDates.htm.

Equity Holders NAME DEPARTMENT EMAIL PHONE

If any above-named individual’s spouse, registered domestic partner, dependent, and/or any other member of his/her household is also a University employee, but is not personally taking an equity interest or establishing any other financial relationship with the company, please provide his or her full name, department affiliation, email and phone number and indicate to whom he or she is related.

NAME DEPARTMENT EMAIL PHONE RELATED EQUITY HOLDER

2. CAPITALIZATION CHART Provide a capitalization chart for the company that includes the proposed equity holdings of the University and/or its faculty, staff, students and members of their immediate families. Explain how ownership percentages are expected to change as additional investors, managers and/or others participate in the company. 3. MANAGEMENT/OPERATING TEAM & BOARD OF DIRECTORS Provide the name, phone number, and e-mail address of all members of the management/operating team and Board of Directors. Attach resumes or biosketches for those filling management/operating positions in the company.

If any University of Pittsburgh faculty, staff and/or students are requesting to hold management/operating positions or serve on the company’s Board of Directors, please contact the COI Office in advance of submitting this form. Please note that this request takes additional time to process and should be submitted to the COI Office no less than two weeks prior to the COI Committee meeting at which this submission will be considered.

POSITION IN COMPANY NAME EMAIL PHONE

4. CONSULTING Describe the proposed role and anticipated time commitments of any University faculty, staff and/or students who will be performing consulting services (such as serving as the Chair or a member of the Scientific Advisory Board) for the company with or without compensation. Written consulting contracts for services must be submitted to the COI Office for compliance review.

5. BUSINESS PLAN Provide a description of products or services to be developed and sold by the company, including information on the current development status of the intellectual property (IP) to be optioned/licensed from the University, and sources of current and future (pending or proposed) funding.

6. OPTION/LICENSE AGREEMENT Provide a description of the type and general terms of the proposed IP agreement between the University and the company, noting any non-standard terms. (Obtain this information from an Innovation Institute licensing manager.) Provide the IP exhibit from the proposed agreement and briefly describe the University technology to be optioned or licensed to the company in a way that is understandable to a general audience. LSC Information Submission Form to COIC Page 3 of 4

List all University-affiliated inventors/authors/developers of the IP that is covered under the option/license agreement, regardless of whether they are taking equity and/or establishing any other financial relationship with the company.

NAME DEPARTMENT EMAIL PHONE

7. EXISTING/PROPOSED COMPANY SPONSORED RESEARCH Provide abstracts with detailed budgets of any existing or proposed research projects to be sponsored by the company at the University (including any that will be funded by SBIRs/STTRs) and describe the participation of any University faculty, staff and/or students in this research. Note the type of research (e.g., bench, human, animal) being conducted and include IRB or IACUC protocol numbers as applicable. These may be provided as attachments.

8. OTHER RESEARCH SUPPORT List all other current or proposed funding supporting research that will be conducted by faculty, staff and/or students who hold equity in and/or have any other financial relationship with the company that is evaluating or developing any products or IP owned by the company (including the IP that is covered under the option/license agreement with the University). Note the type of research (e.g., bench, human, animal) being conducted and include IRB or IACUC protocol numbers as applicable. If you are unsure whether a research project is evaluating or developing products or IP owned by the company, please contact the COI Office.

9. PUBLIC HEALTH SERVICE (PHS) RESEARCH SUPPORT For each individual who holds equity in and/or has any other financial relationship with the company, provide the full grant/contract number, title, and name of the PI for all awards from any agency of the PHS not listed under item 8 under which s/he is participating in the design, conduct, or reporting of research funded by such awards. (You may provide this information as a separate attachment.) A list of PHS agencies can be found at http://www.coi.pitt.edu/PHS/index.htm.

10. Provide signed POLICY COMPLIANCE STATEMENTS from all faculty, staff and/or students taking equity in the company stating that they understand and will comply with all relevant University policies.

Revised: November 2017 These statements MUST be received by the COI Office before 8AM on the day of the COIC meeting on which this submission will be considered.

11. Provide signed APPROVAL OF ENTREPRENEURIAL ACTIVITIES OF FACULTY MEMBER forms by Department Chairs or Deans documenting their approval of the proposed involvement of faculty in the entrepreneurial endeavor. Do not use this form if you are requesting to hold more than 49% equity in the company or to have management or officer positions. The COI Office will provide customized approval forms to your supervisors as part of the review process. These forms MUST be received by the COI Office before 8AM on the day of the COIC meeting on which this submission will be considered.

12. Provide signed NOTIFICATION TO STUDENTS/STAFF OF FINANCIAL INTEREST IN A LICENSED START-UP COMPANY forms from students/staff who will be performing work related to the commercial interests of the company. These forms should be submitted to the COI Office within two weeks after the submission is approved by the COIC.

Signatures of all faculty, staff, and/or students who will be taking equity in the company:

NAME: DATE

Return completed and signed form electronically to Khrys Myrddin ([email protected]; 412-383-2828) or send a hard copy to COI Committee, c/o COI Office, Hieber Building, Ground Floor, 3500 Fifth Avenue, Pittsburgh, PA 15213

The signed, final version of this form must be received by noon on Wednesday of the week of the COI Committee meeting on which this submission will be considered.