Collaboration Request Form Please complete this form in order to schedule a project discovery meeting with the appropriate Durham College personnel.Primary Contact InformationName* First Last Title*Phone NumberMobile NumberEmail* Business InformationBusiness Name*Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Main Telephone*FaxWebsite Date of Incorporation Is the business based in Ontario*YesNoWhat is your Business Identification Number (BIN)*What are the North American Industry Classification Systems (NAICS) codes of the business?What is the legal form of the business*CorporationPartnershipSole ProprietorshipNumber of years in business*0 - 1 (startup)2 - 55+Number of employees in Ontario*Are any owners or employees related to any employees at Durham College or other Ontario post-secondary institutions?*NoYesIf yes, please describeIs the business currently working, or has worked, in collaboration with any other Ontario post-secondary institutions receiving provincial or federal research funding?*NoYesIf yes, please describeHow did you learn about Durham College applied research and collaboration?*Potential Project InformationProject Name*What is your product/service?*What is the problem your product/service will solve?*What assistance do you need to solve the problem?*Describe your target market.*Who are your competitors?*What key features does your solution offer that others cannot?*Is your product/service IP (Intellectual Property) protected? Do you own the IP outright? Is the ownership based in Ontario?*Do you have a handful of potential customers who have agreed that they would buy your product/service for the price you are asking if it were available now for sale? You will be asked to provide proof of this.*What steps have you taken so far in developing your product/service and what are the key challenges you now face?*What resources, help, expertise, equipment, workspace or other resources do you need from Durham College for this project?*Check all that apply. Assistance in obtaining matching funding Faculty expertise Providing team of students Access to space and equipment Project management Other (please specify below) What are you prepared to contribute to the project? Check all that apply.* Cash (mandatory) Staff time Equipment Materials Other (please specify) Documents that support the project (e.g. business plan, etc.).Estimate how many full/part time jobs this project might lead to and in which area?*Start Date (Desired)* Completion Date (Desired)* Durham College values the opportunity to provide you with information on our programs, events, unique business and partnership opportunities, services and more. Under the Canadian Anti-Spam Legislation, we require your consent to contact you via email with this information.*Please check the appropriate box below:I consent to receive promotional email messages from Durham College.Do not send me promotional email messages from Durham College.