1. US Connect 2011 Application

2. Acknowledgement of Terms By submitting this application, you acknowledge that: 1.You have reviewed the US Connect 2011 program description at www.utenportugal.org/usconnect.www.utenportugal.org/usconnect 2.Your venture and technology was connected prior to this application to a Portuguese University Technology Transfer Office, a Portuguese incubator or has another substantial connection to a Portuguese public university. 3.The CEO or a senior staff member has the time available to travel for two weeks in the U.S. in support of US Connect goals for your venture. 4.Your venture has the financial resources in hand needed to fund your travel, including airfare, hotels, meals, and U.S. domestic travel expenses, for an estimated total of US$6,000. 5.You agree to supply formal verification of your financial resources if you are accepted into the program.

3. Company / Venture Overview Company or Venture Name Physical Address Primary Contact Name Contact Email Contact Phone Number Web Site

4. Portuguese University Connection Describe your connection to a Portuguese University Technology Transfer Office (TTO), a Portuguese technology incubator, or some other substantial connection to a Portuguese public university. TTO or Incubator Contact Name Email Address

5. Senior Staff NameTitleEmail

6. On the following pages, please limit your response to the space provided using Calibri 16 point font. Do not modify the text size or style. Content that does not fit in the available space using the specified size and style will be deleted prior to review.

7. Company / Venture Description Describe your company or venture. Include general information, a short statement of your mission, and the products, services, and/or value-add you bring to the market. Description.

8. Product or Service Description Describe your product or service. Explain the benefits of your product or service as viewed by your customers and prospects. Description.

9. Users of this Product NameDate Delivered Paying Customer? International Customer? YES no How many overall customers use this product? nnn

10. Intellectual Property DescriptionDate Type Patent, TM, ©, Trade Secret, Other If a Patent: Indicate Provisional, PCT, and/or countries where granted Status Filed, Granted Application or Patent #

11. Investment and Revenue 2008 Gross Revenue 2009 Gross Revenue 2010 Gross Revenue YearAmountDescription 2008 Cash Awards / Investment 2009 Cash Awards / Investment 2010 Cash Awards / Investment A cash award includes competition prizes and any other cash received that was not in return for a stake in the venture. Ventures accepted into US Connect will be asked for formal verification of results reported in this application.

12. Comment on the domestic and other recent successes you can build on and why you believe it positions your venture for international expansion.

13. Summarize U.S./international market research or business development efforts made to date, and assess your product’s international potential. Text

14. Summarize the benefits your product offers to potential customers, partners and other collaborators in the U.S. and international markets, and your competitive advantage over other solutions. Text

15. Identify any additional international prospects, established partners or potential partners not previously mentioned. NameType: Prospect, Established Partner, Potential Partner, Other Comment

16. Indicate if the CEO will travel to the U.S. to support the effort. If the CEO will not travel, please explain why the other staff member is a better selection for the trip, and confirm that staff member will have authority to act during the trip. For small ventures, strong preference will be given to ventures whose CEO will travel. Who will travel to support US Connect? (underline selection) CEO Another Senior Staff Member (indicate name): If someone other than the CEO will travel, elaborate on the reason below.

17. Summarize your case for why your venture and product will benefit from and be successful in the US Connect program. Text

18. Submitting Your Application 1.You may attach additional information to your application. 2.Reviewers are not obligated to examine additional information. Information that is concise and relevant is more likely to be reviewed. 3.This application form will be the primary source of information for our reviewers. 4.We reserve the right to contact applicants for clarifications, at our sole discretion. 5.For any questions about the application process, email us at usconnect@utenportugal.org. usconnect@utenportugal.org

19. Submitting Your Application Set the Subject Line of your email to: US Connect 2011 Application: Email your completed application to usconnect@utenportugal.org. usconnect@utenportugal.org UTEN staff will email you confirmation of application receipt.