NIH Applicant Assistance Program Application Only one application may be submitted per company for each round of the AAP. Applicant Information1. Applicant Name*(PI on proposed application) First Last Phone Number*Alternate PhoneEmail Address* Enter Email Confirm Email 2. Applicant role within company (e.g. Founder, CEO, Senior Scientist, etc.)* 3. Applicant Small Business Name*If a small business has not yet been registered, enter TBD in place of business name.4. Where is the operating location of the Small Business?* Street Address Address Line 2 City ZIP / Postal Code State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAmerican SamoaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPuerto RicoPalauVirgin IslandsState5. Will a University be affiliated with the project?*YesNoName of University6. Description of Women and Minority Involvement in SBC Ownership and Leadership*The following racial and ethnic groups have been shown to be underrepresented in health-related sciences in the United States: African Americans, American Indians and Alaska Natives, Hispanics (or Latinos), Native Hawaiians and other Pacific Islanders. For more information: https://extramural-diversity.nih.gov/diversity-matters/underrepresented-groupsWoman OwnershipMinority OwnershipPrefer not to answer0%>0% - <51%> 51%Prefer not to answer0%>0% - <51%> 51%Please describe woman/minority involvement in Founder and C-Suite roles (if applicable) Woman Founder Woman in C-Level Leadership Role Founder from an Underrepresented Minority Group C-Level Leader from an Underrepresented Minority Group What race/ethnicity does the Founder identify with? African American American Indian and Alaska Native Hispanic (or Latino) Native Hawaiian Other Pacific Islander Other Prefer Not To State What race/ethnicity does the C-Level Leader identify with? African American American Indian and Alaska Native Hispanic (or Latino) Native Hawaiian Other Pacific Islander Other Prefer Not To State 7. Are you seeking support through the AAP to help prepare a new SBIR/STTR application or to assist you in resubmitting an amended application?*New ApplicationResubmissionPrevious Grant Number8. Did the small business or the PI submit an SBIR/STTR application with the same scope of work for the September 5, 2019 due date?*Yes (Ineligible for AAP)No9. What is the previous experience of the small business with NIH SBIR/STTR funding?*Have not appliedHave not been successfulHave received NIH SBIR/STTR award(s) in the past 10 years (Ineligible for AAP)Have received NIH SBIR/STTR award(s), with the most recent award received prior to 2010 (Eligible for AAP)10. What is the previous experience of the proposed project Principal Investigator (PI) with NIH SBIR/STTR Funding?*Have not appliedHave not been successfulHave received NIH SBIR/STTR award(s)Technology Information1. What type of technology will you be developing in your proposed SBIR/STTR project?* Drug Research Tool Combination Product Medical Device Diagnostic Health IT / Education Other Please Specify2. Project Title (limit 200 characters)*3. Project Abstract. Please upload a pdf file of 1 page or less. Any text over the 1 page limit will be automatically deleted (pdf only, 10MB limit).*For consideration by most participating Institutes the abstract must identify the intended disease or use case for the technology, and indicate the technology development goal for which the applicant will seek SBIR/STTR grant support.Accepted file types: pdf.4. Describe the current state of the technology and a high-level description of any preliminary data that has been generated thus far. Please upload a pdf file of 1 page or less. Any text over the 1 page limit will be automatically deleted. You may include figures and tables, within the 1 page limit, but please do not include any web links (pdf only, 10MB limit).*Accepted file types: pdf.Network1. What resources are available to you?* Registration Support Proposal writing/development Proposal review Budget preparation Expertise in technology development Access to Key Opinion Leader(s) Physical location to carry out the proposed work Support in uploading and submitting proposal Other Please Specify2. Have you reached out to your local SCORE or SBDC for assistance with any aspect of your small business?*Visit SCORE or visit SBDC for more informationYesNo3. List additional areas in which you need support:*4. Do you agree to spend 10-25 hours per week during the training period working on your SBIR/STTR application?*YesNo5. What Institute Are You Applying To?*National Cancer Institute (NCI)National Institute of Neurological Disorders and Stroke (NINDS)National Institute on Aging (NIA)National Heart, Lung, and Blood Institute (NHLBI) Before submitting, please ensure that your email address and phone number have been accurately entered, as they will be used to notify you regarding your application status. CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.