4040-0001 SBIR/STTR Information

SBIR/STTR Information

OMB Number: 4040-0001
Expiration date: 06/30/2011

* Program Type (select only one)
SBIR

STTR

Both (See agency-specific instructions to determine whether a particular agency allows a single submission for both SBIR and STTR)
* SBIR/STTR Type (select only one)
Phase I

Phase II

Fast-Track (See agency-specific instructions to determine whether a particular agency participates in Fast-Track)

Questions 1-7 must be completed by all SBIR and STTR Applicants:
Yes
No

* 1a. Do you certify that at the time of award your organization will meet the eligibility criteria for a small business as defined in the funding
opportunity announcement?
* 1b. Anticipated Number of personnel to be employed at your organization at the time of award.

Yes
No

* 2. Does this application include subcontracts with Federal laboratories or any other Federal Government agencies?
* If yes, insert the names of the Federal laboratories/agencies:

No

* 3. Are you located in a HUBZone? To find out if your business is in a HUBZone, use the mapping utility provided by the Small Business
Administration at its web site: http://www.sba.gov

Yes

* 4. Will all research and development on the project be performed in its entirety in the United States?

Yes

No

If no, provide an explanation in an attached file.
* Explanation:

Yes
No

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* 5. Has the applicant and/or Program Director/Principal Investigator submitted proposals for essentially equivalent work under other
Federal program solicitations or received other Federal awards for essentially equivalent work?
* If yes, insert the names of the other Federal agencies:

Yes
No

* 6. Disclosure Permission Statement: If this application does not result in an award, is the Government permitted to disclose the title of
your proposed project, and the name, address, telephone number and e-mail address of the official signing for the applicant organization,
to organizations that may be interested in contacting you for further information (e.g., possible collaborations, investment)?
* 7. Commercialization Plan: If you are submitting a Phase II or Phase I/Phase II Fast-Track Application, include a
Commercialization Plan in accordance with the agency announcement and/or agency-specific instructions.
* Attach File:

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SBIR/STTR Information
SBIR-Specific Questions:
Questions 8 and 9 apply only to SBIR applications. If you are submitting ONLY an STTR application, leave questions 8 and 9 blank and proceed to
question 10.
Yes
No

* 8. Have you received SBIR Phase II awards from the Federal Government? If yes, provide a company commercialization history in
accordance with agency-specific instructions using this attachment.
* Attach File:

Yes

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* 9. Will the Project Director/Principal Investigator have his/her primary employment with the small business at the time of award?

No

STTR-Specific Questions:
Questions 10 and 11 apply only to STTR applications. If you are submitting ONLY an SBIR application, leave questions 10 and 11 blank.

Yes
No

Yes
No

* 10. Please indicate whether the answer to BOTH of the following questions is TRUE:
(1) Does the Project Director/Principal Investigator have a formal appointment or commitment either with the small business directly
(as an employee or a contractor) OR as an employee of the Research Institution, which in turn has made a commitment to the
small business through the STTR application process; AND
(2) Will the Project Director/Principal Investigator devote at least 10% effort to the proposed project?
* 11. In the joint research and development proposed in this project, does the small business perform at least 40% of the work and the research
institution named in the application perform at least 30% of the work?