CONFIDENTIAL

SynergiQc
Application Form / For internal use
File # :

This form must be filled in with “Arial 11” font, typed at 1.15 line spacing

Please also submit with your application the SynergiQcBudget form(available upon request to CQDM )

Duration of the Project
Total Amount of the Project
Amount Requested from CQDM / [Amount] /
SECTION 1A. TITLE OF THE PROJECT (English)
SECTION 1B.TITRE DU PROJET (en français)
SECTION 1C. TECHNOLOGY READINESS LEVEL (at the beginning of the project)
Indicate the levelof technology readiness at the beginning of your project(see “TRL extendeddefinition CQDM”tableon CQDM website; please contact CQDM if you have any questions)
☐ TRL2: Hypothesis and experimental design developed
☐ TRL3: Analytical and experimental critical function demonstrated
☐ TRL4: Experimental proof-of-concept completed
☐ TRL5: Fully validated in relevant laboratory environment
☐ TRL6: Tested in relevant end-user environment (pilot scale)
Briefly justify the TRL of your project, also mentioning what will the TRL beat the end of the project.
SECTION 2A. LAYMAN SUMMARY OF THE PROJECT (in English, maximum 10 lines)
Provide a summary of your project to be understandable by a non-scientific audience.
Do not include any confidential information in this summary, since CQDM and its partners may use this summary for publication.

Add text here

SECTION 2B. RÉSUMÉ VULGARISÉ DU PROJET (en français, maximum 10 lignes)
Ce résumé doit être compréhensible par une audience n’ayant pas de connaissance scientifique approfondie.
Puisque le CQDM et ses partenaires pourraient publier ce résumé, il ne doit contenir aucune information confidentielle.

Add text here

SECTION 3. IDENTIFICATION OF THE TEAM OF INVESTIFATORS
SECTION 3A IDENTIFICATION OF THE PRINCIPAL INVESTIGATOR (PI, must be in Academia)
Last name: / First name:
University/Department
Address:
City: / Province: / Quebec / Postal Code:
Country: / Canada / Phone #: / Ext:
Email:
SECTION 3B.IDENTIFICATION OF THE RESEARCH GROUP (PI, CO-PI (CP) and CO-INVESTIGATORS (CI); including those from private organizations)Add lines if necessary
Numeration
(to be used in sections3C & 7B) / Name / Affiliation
Also Indicate if Private sector (P) or Academia (A) / Email / Contribution to the project (refer to milestones in Gantt) / % of the budget allocated
1
2
3
4
5
6
7
8
SECTION 3C. CORPORATE INFORMATION (1 page per organisation)
Name, location, website:
Contact (name, title, phone, & email):
Incorporation date:Number of employees:
Provide a global overview of the industrial partner involved:
  • Mission;
  • Sector of activity;
  • Business model;
  • Discuss how the proposed project is aligned with its overall corporate objectives;

Add text here

SECTION 3D. ROLE OF EACH OF THE ORGANIZATIONS (SMEs and Academia) AND DESCRIPTION OF THE TEAM (maximum 2 pages)
Discuss the role of the PIs and each co-investigators (listed in section 3B) with direct contributions in the research project;
Describe the role of each industrial partners involved in the project;
Describe their experience and expertise relevant to the proposed project for each team member, emphasizing on how they are essential to the project; Describe the added value of the collaboration;
Discuss the synergies and complementarities of the team members.

Add text here

SECTION 4. SUMMARY OF THE PROJECT (1page)
Define the following aspects of your project: brief rationale, current state of advancement of the technology, preliminary data, objectives, experimental approach and brief research plan. Indicate most important milestones of the proposed project. Lay out the future development plans for the technology to be fully usable by the industrial partner.

Add text here

SECTION 5A. COMPETITIVENESS AND POSITIONING OF THE PROPOSED TECHNOLOGY(1/2page)
Describe the innovativeness and the originality of the proposed research compared to existing technologies (or in development) worldwide;
Describe the added value of the technology with regards to international competing technologies used to achieve similar readouts or goals.

Add text here

SECTION 5B. ECONOMIC IMPACT OF THE PROJECT (1/2page)
Describe how the project will allow the industrial partners to reach value-creating milestones;
Describe how the technology will be integrated and used by the industrial partners;
Mention how the success of the project will impact the academic partners;
Describe the social and economic benefits for Quebec upon successful completion of the project, including, but not exclusively, the impact of the project on the Québec life sciences ecosystem and the training of highly qualified personal.

Add text here

SECTION 6. FULL DESCRIPTION OF THE PROJECT(maximum 6 pages, including figures and tables; please include references in Appendix)
Describe the project by outlining the following aspects of your research:
  • Background and preliminary results
  • Objectives
  • Experimental approach and Research Plan
  • Experimental/Methodological approach (Include appropriate power analysis for animal and human studies. For human studies, define the recruitment process and elaborate on your ability to recruit the necessary number of patients)
  • Expected results and readouts
  • Milestones and go/no go decision points: Milestones are major events or significant steps in a project. Make sure to define your project with a milestone at every 6 months. Each milestone should be accompanied with a specific set of metrics that allows a third party to assess progress. If the project is completely dependent on a specific milestone, address it as a go/no go decision point. This should closely follow the Gantt chart in section 7.
  • Deliverables:Define the tangible, concrete assets that will result from this work and its intended use in the field of biopharmaceutical. Explain how and in what form the deliverables may be transferable to intended end-users.

Add text here

SECTION 7. MILESTONES and TIMELINES (Gantt chart; maximum 1 page)
1)Insert a Gantt chart illustrating the principal steps of the project as well as milestones, deliverables and go/no go decision points (as described under section 6).
2)Identify in the Gantt chart the specific contribution of the PI, co-PI, and co-investigators* at the different steps of the project and specify the cost of each step.
*by referring to the numbers associated with the investigators as listed in section 3B

Add text here

SECTION 8. DEVELOPMENT PLAN and COMMERCIALIzATION OPPORTUNITIES (1 page)
Describe the various steps of the technological development plan and technological maturation that would be required to deploy and commercialize the technology and/or ensure its usability by theindustry or intended end-users (validation, manufacturing, scale-up, regulation, foreground and background IP, etc.), including a brief tentative timeline.
Outline the opportunities the technology will create for the biopharmaceutical R&D sector. Describe the potential commercial value and the market need the technology will fill.

Add text here

SECTION 9.1SUMMARIZED BUDGET *
ESTIMATED COSTS OF PROJECT / Year 1
(in thousands $) / Year 2
(in thousands $) / Year 3
(in thousands $) / TOTAL
(in thousands $)
Salaries and benefits (research staff, students, etc)
Material and supplies
Travel expenses (conferences, seminars, symposia fieldwork)
Publication and dissemination costs
Consulting and subcontracting services
Other (please specify)
Intellectual property costs
TOTAL PER YEAR
*Please note that a detailed budget is also required and must be submitted using the:
“SynergiQcBudget Form”
Fill in this table concerning the financial structure of the projectincluding all sources of funding for this project.
Name ofcontributors / Public or private / Contribution ($) / Specify in kind or in cash / Is the contribution secured? / Expected date to secure contribution
1.
2.
3..
4.
5.
AMOUNT REQUESTED FROM CQDM
TOTAL BUDGET
SECTION 9.2 Budget Justification(1 page)
Justify the budget for each major item presented in the table above, emphasising on training of highly qualified personnel.

Add text here

SECTION 10. INTELLECTUAL PROPERTY
10A. IS THERE ANY PRE-EXISTING INTELLECTUAL PROPERTY (IP) LINKED TO YOUR PROJECT? ☐Yes ☐No
If yes, please answer the following questions (maximum 1 page):
  1. Is the background IP necessary to use the proposed technology?
  2. Who are the IP owners?
  3. What is the invention?
  4. Who holds the rights to the IP?
  5. Do the principal investigator and the co-investigators of this project have the legal authorization to use the pre-existing IP?

Add text here

10B. WILL YOUR PROJECT GENERATE NEW INTELLECTUAL PROPERTY (IP)?☐Yes☐No
If yes, please describe (maximum 1 page):
1)Will the technology result in the creation of new IP?
2)Who will be the inventor(s)?
3)Who will hold the IP rights?
4)Describe the overall strategy regarding data and IP sharing.

Add Text here

SECTION 11A. SIGNATURE OF PI
Please note that this form must be signed by the PI
1. I authorize CQDM to exchange all information relating to this application for analysis or evaluation purposes, provided that all persons granted access to this information treat it in the strictest confidence.
2. I understand that the intellectual property resulting from this project will belong to the inventor(s) and their institutions.
3. I agree that, if this project is retained for funding, I will facilitate the signing of an agreement with respect to the funding and no later than 3 months following the confirmation of the funding.
4. I certify that all information provided in this application is complete and accurate to the best of my knowledge.
Signature of the PI:
Name:
Date:
Name Organisation
Research entity representative signature :
SECTION 11B. SIGNATURE OF CO-PI AND CO-INVESTIGATORS (copy and add pages, if necessary)
Please note that this form must be signed by the Co-PI(if appropriate) and all co-investigatorsas well as all research entity representatives.
1.I authorize CQDM to exchange all information relating to this application for analysis or evaluation purposes, provided that all persons granted access to this information treat it in the strictest confidence.
2.I understand that the intellectual property resulting from this project will belong to the inventor(s) and their institutions.
3.I agree that, if this project is retained for funding, I will facilitate the signing of an agreement and no later than 3 months following the confirmation of the funding.
4.I certify that all information provided in this application is complete and accurate to the best of my knowledge.
Signature of theco-principal investigator (if appropriate):
Name:
Date:
Organisation
Research entity representative signature
Signature of the co-investigator:
Name:
Date:
Research entity signature (if different)
Signature of the co-investigator:
Name:
Date:
Research entity signature (if different):
SECTION 11C. SIGNATURE OF INDUSTRIAL PARTNERS OR OTHER PRIVATE ENTITIES
Please note that this form must be signed by an authorised representative of each industrial/private partner
1.I authorize CQDM to exchange all information relating to this application for analysis or evaluation purposes, provided that all persons granted access to this information treat it in the strictest confidence.
2.I understand that the intellectual property resulting from this project will belong to the inventor(s) and their institutions.
3.I agree that, if this project is retained for funding, I will facilitate the signing of an agreement and no later than 3 months following the confirmation of the funding.
4.I certify that all information provided in this application is complete and accurate to the best of my knowledge.
Signature of the authorised industrial
partner/private partner representative :
Name:
Date:
Name of organisation
Signature of the authorised industrial partner/private partner representative:
Name:
Date:
Name of organisation:
Signature of the authorised industrial partner/private partner representative
Name:
Date:
Name of organisation:

SynergiQc Application Form 2017Page 1 of 19