Submission form for potential cooperation partners
Courtesy title
Dr.
Mr.
Miss.
Ms.
First Name*:
Last Name*:
E-Mail*:
Address*:
Zip Code*:
City*:
Phone:
Country*:
Employer:
Fax:
1.
Descriptive title (incl. indication)
(max. 15 words)
2.
Description of the activity of the compound in
in vitro
assays
(max. 50 words)
3.
Description of the activity of the compound in animal models
(Mention route of administration)
(max. 50 words)
4.
Availability of toxicological (pre-clinical) and/or clinical data
Toxicological data
Yes
No
If yes:
Genotox
in vitro
Acute/one species
One week/at least one species
One month/at least one species
Three months/at least one species
Teratogenicity
in vivo
Lifetime carcinogenicity
Full registration package
Clinical data
Yes
No
If yes:
Phase 1
Phase 2
Phase 3
Comments
(max. 50 words)
5.
Patent protection
Yes
No
If yes:
1) Kind of patent
Composition of matter
Use
2) Geographic coverage
N. America
Europe
Japan
others
3) Patent expiry
>15 years
10-15 years
5-10 years
<5 years
Please give a brief,
non-confidential
description of the opportunity covering the following points:
Distinctiveness of the compound vis-à-vis products on the market
Key data to support the proposal
Key
in vitro
and
in vivo
experimental models used
Existing collaborations in the field
Please be aware that if you disclose information to us which is not already the subject of
a filed patent such disclosure may be considered to be a publication and may jeopardise
any future patent application.
(max 150 words)*
* mandatory fields