Israel-Canada Collaborative Industry R&D ProgramExpression of Interest Form

1. Project Participant

Company name: __________________

Website: ________________________

Year established: _________________

Type of company: __R&D __ Research institute __ University __ Other

Stage: __ R&D __ Initial revenues __ Revenue growth

Ownership: __ Public __ Private __ Governmental __ Other

Number of employees: ____

Number of R&D personnel: ____

Company contact information:

Address: __________________________________________________.

Contact person:

Name: _________________________

Title: __________________________

Phone: ________________________

Mobile: ________________________

Email: _________________________

2. Organization Background

General Business Description & Area of Expertise

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Technology Description (Main Products/Services) and IP

Targeted Customers

____________________________________________________________________________________________________________________________________________________________________________________________________________________

Sales (over the last 3 years)

Current year: ________________

Year-1 _________________________

Year-2 ________________________

3. General Information

Project Title: ________________________________________________________

Technology Sector:

________________________________________________________

Submission Date: __/__/____

Summary:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Project Start Date: __/__/____

Project End Date: __/__/____

4. Budget:

Total Project Budget: __________________________

Requested Grant (% of budget): _________________________

5. Project Outline:

Project Description Including Level of Innovation

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Market Potential and Commercialization Plan

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Expected Outcome of Project

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Short Profile of the Key Staff who will be Undertaking the Work ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________