Technology Commercialization Assessment

First Name *

Last Name *

Company Name *

Email Address *

Work Phone *

Work Address *

City *

State * Select State Alaska Alabama Arkansas American Samoa (see also separate entry under AS) Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Guam (see also separate entry under GU) Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Northern Mariana Islands (see also separate entry MP) Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico (see also separate entry under PR) Rhode Island South Carolina South Dakota Tennessee Texas U.S. Minor Outlying Islands (cf. separate entry UM) Utah Virginia Virgin Islands of the U.S. (see also separate entry VI) Vermont Washington Wisconsin West Virginia Wyoming

Zip Code *

Industry Type * --Please Select-- IT Hardware IT Software Chip Technology Bio Medical Bio Chemical Energy Other

If other industry type, explain

Time in business --Please Select-- N/A 0-6 months 7-12 months 13 months or more

Annual revenue

Have you seen an SBDC Counselor recently * --Please Select-- No Within 6 months Within 7 to 12 months Over 12 months

Referred from * --Please Select-- Small Business Development Center Small Business Administration MD Department of Business and Economic Devlopment County Economic Development Corporation TEDCO Industry Partner Federal Lab University Montgomery County Incubator Other Incubator Other None

Check areas in which you are seeking support *
SBIR Support Technology Transfer and Licensing Intellectual Property Protection Support Product Commercialization/Planning Alternative Financial Sources Market Research Support Training Counseling Other

Are you engaged in Research and Development? * --Please Select-- Yes No

Comments about areas in which you are seeking support