FMA Application Step 1 of 11 9% InstructionsThe Federal Marketing Assistance (FMA) program has been developed to improve your competitive position in pursuing SBIR/STTR Phase II proposals or advanced federal R&D opportunities. This application form requests information that the IPart will use in evaluating the appropriateness and quality of your request – a decision to make an award will be based on your responses. It is vitally important that your responses be complete enough to make an informed assessment. However, please be concise and recognize that we do not ask for a detailed technical discussion of your products or company. READ EACH QUESTION CAREFULLY and make certain you provide the information requested. The estimated time to complete this application is approximately two hours. Please read the entire application prior to starting – this will help you in gathering materials and completing the application efficiently. FOR QUESTIONS – please contact the Innovation Partnership representative who provided the application to you or the IPart Director – Kelly S. Wylam kelly@benfranklin.org (717) 948-4318 Click here for application tips for funding success from the Innovation Partnership Investment Committee.Navigating Through This Application This application form consists of multiple pages. You can navigate between them using the Next and Previous buttons at the bottom of each page. You may save your application at any point by clicking save. You will be given a link to return to your application form. Do not lose this link; it is essentially your password. You have 30 days to return after saving your progress.All questions marked with a "*" are required for completion. I have reviewed the "Application Tips for Funding Success" with my sponsor.* Yes No Applicant Type*Please ChooseAcademic InstitutionC-CorpLLCPartnershipS-CorpSole ProprietorshipTrustOtherIf "Other," please describe.Which assistance program are you applying for?*Please ChooseFederal Marketing AssistanceMicrovoucher ReviewMicrogrant ReviewTechnical Review Applicant Information All questions marked with a "*" are required for completion.Formal name of the organization or company submitting the federal proposal*Fed Tax ID # (FEIN) 8 digit format (##-######)*Organization Website (URL), if applicablePrimary Contact First Name*Primary Contact Last Name*Title*Phone*Alternate PhoneEmail* Address*City*State*Please ChooseAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZIP Code (00000-0000)*Look up your full ZIP Code here.Please indicate if the applicant is: Woman-Owned Minority-Owned Veteran-Owned Minority Status (if applicable)Please ChooseAsian or Pacific IslanderBlack or African AmericanCaucasianHispanic or LatinoMulti-Racial (not Hispanic)OtherIf "Other," please describe Company Information All questions marked with a "*" are required for completion.Primary (six digit) NAICS Code*Click here to find your NAICS Code.Please identify your firm's main business activity*Please ChooseAGR - Agriculture/Food ProcessingAUT - Factory AutomationBIO - Biotech/Life SciencesCHE - ChemicalsCOM - Computer HardwareDEF - DefenseEDU - EducationENR - EnergyENV - EnvironmentMAN - Manufacturing EquipmentMAT - Advanced MaterialsMED - MedicalNAN - NanotechnologyPHA - PharmaceuticalsPHO - Photonics/OpticsSOF - Computer SoftwareTAM - Testing/MeasurementTEL - Telecommunications/InternetTRN - TransporationOtherIf "Other," please specifyPlease identify your firm's secondary business activityPlease ChooseAGR - Agriculture/Food ProcessingAUT - Factory AutomationBIO - Biotech/Life SciencesCHE - ChemicalsCOM - Computer HardwareDEF - DefenseEDU - EducationENR - EnergyENV - EnvironmentMAN - Manufacturing EquipmentMAT - Advanced MaterialsMED - MedicalNAN - NanotechnologyPHA - PharmaceuticalsPHO - Photonics/OpticsSOF - Computer SoftwareTAM - Testing/MeasurementTEL - Telecommunications/InternetTRN - TransporationOtherHow many patents have been issued to your company? (Please type 0 if none)*How many (if any) patents do you expect to be issued between now and the next 3 years? (Please type 0 if none)*Full-time employees based in Pennsylvania (Please type 0 if none)*Part-time employees based in Pennsylvania (Please type 0 if none)*Full-time employees worldwide (Please type 0 if none)*Part-time employees worldwide (Please type 0 if none)*Full-time PA-based manufacturing or development subcontractors (Please type 0 if none)*Part-time PA-based manufacturing or development subcontractors (Please type 0 if none)*Please select a year and provide your company's revenue for the last 3 years (excluding grants & loans).Current Year2016201720182019202020212022202320242025Current Year RevenueLast Year2016201720182019202020212022202320242025Last Year Revenue2 Years Ago20162017201820192020202120222023202420252 Years Ago Revenue Location All questions marked with a "*" are required for completion.County*Please ChooseAdamsAlleghenyArmstrongBeaverBedfordBerksBlairBradfordBucksButlerCambriaCameronCarbonCentreChesterClarionClearfieldClintonColumbiaCrawfordCumberlandDauphinDelawareElkErieFayetteForestFranklinFultonGreeneHuntingdonIndianaJeffersonJuniataLackawannaLancasterLawrenceLebanonLehighLuzerneLycomingMcKeanMercerMifflinMonroeMontgomeryMontourNorthamptonNorthumberlandPerryPhiladelphiaPikePotterSchuylkillSnyderSomersetSullivanSusquehannaTiogaUnionVenangoWarrenWashingtonWayneWestmorelandWyomingYorkCongressional District Number*Click here to find your Congressional District Number.PA State House of Representatives District Number*Click here to find your State House of Representatives District Number.PA State Senate District Number*Click here to find your State House of Representatives District Number. Referred By All questions marked with a "*" are required for completion.What organization invited you into the Innovation Partnership MicroGrant Program?*Please ChooseBen Franklin TP of Central & No. PABen Franklin TP of Northeastern PABen Franklin TP of Southeastern PACatalyst ConnectionDelaware Valley IRC (DVIRC)Innovation Works (BFTP of Southwestern PA)Life Sciences Greenhouse of Central PAManufacturers Resource Center (MRC)Manufacturing Technology IRC (MANTEC)Northeastern PA IRC (NEPIRC)Northwest PA IRC (NWPIRC)PA BioTechPenn State UniversityPENNTAPPittsburgh Life Science GreenhouseSBDC Bucknell UniversitySBDC Clarion UniversitySBDC Duquesne UniversitySBDC Gannon UniversitySBDC Kutztown UniversitySBDC Lehigh UniversitySBDC Lock Haven UniversitySBDC Penn State UniversitySBDC Saint Francis UniversitySBDC Saint Vincent UniversitySBDC Temple UniversitySBDC University of PittsburghSBDC University of ScrantonSBDC Wharton SchoolSBDC Wilkes UniversityThe Industrial Modernization Center (IMC)]University City Science CenterUniversity of Pittsburgh OEDOtherIf "Other," please describe Company Overview Please provide a brief overview of your company. This should include: years in operation, sources of technology, core competencies, target markets, products, and drivers of product development. Also include present size (annual sales and number of employees), current products/services that have significant sales, and a very brief indication of how you will grow and maintain your business. All questions marked with a "*" are required for completion.Company overview:* Previous Federal Grant Experience Have you or your organization applied for federal grants in the past? If so, please describe: Approximate number of proposalsWhat type were the majority of your previous awards?Please ChooseSBIRSTTRATPBAAGovernment ContractPlease identify the Federal agencies where you have submitted applications (check all that apply): Dept. of Commerce DOD Dept. of Education Dept. of Energy DHS DOT EPA NASA NIH NSF USDA First year a proposal was submitted: (format yyyy)Last year a proposal was submitted: (format yyyy)Have you or your organization previously received federal grant funding? If so, please describe:Approximate no. of awards received by the company currently making application:Approximate no. of awards received by you under other companies:What type were the majority of previous awards received by the company currently applying:Please ChooseSBIRSTTRATPBAAGovernment ContractApproximate total dollar amount of awards to this company:First year an award received by this company: (format yyyy)Last year an award received by this company: (format yyyy) Targeted Grant Program Description All questions marked with a "*" are required for completion.What type of proposal are you planning?*Please ChooseSBIR Phase ISBIR Phase IISTTR Phase ISTTR Phase IIFast TrackATPBAAOther(Describe if other)To which DOD agency are you applying?*Please ChooseAir ForceArmyDARPAMDANavyIf applying to the NIH, please indicate which Institute:*Please ChooseNCI (National Cancer Institute)NEI (National Eye Institute)NHLBI (National Heart, Lung, and Blood Institute)NIA (National Institute on Aging)NIAAA (National Institute on Alcohol Abuse and Alcoholism)NIAID (National Institute of Allergy and Infectious Diseases)NIAMS (National Institute of Arthritis and Musculoskeletal and Skin Diseases)NIBIB (National Institute of Biomedical Imaging and Bioengineering)NICHD (National Institute of Child Health and Human Development)NIDCD (National Institute on Deafness and Other Communication Disorders)NIDCR (National Institute of Dental and Craniofacial Research)NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases)NIDA (National Institute on Drug Abuse)NIEHS (National Institute of Environmental Health Sciences)NIGMS (National Institute of General Medical Sciences)NIMH">NIMH (National Institute of Mental Health)NINDS (National Institute of Neurological Disorders and Stroke)NINR (National Institute of Nursing Research)NLM (National Library of Medicine)Proposal due date (format mm/dd/yyyy)*If available, please copy the URL of the web page containing the research topic description in the solicitation or program announcement. (Note: If the research topics have not yet been announced, please leave this section blank.)URLIn its published solicitation, each federal agency lists the various research topics for which projects will be selected. In order to receive funding, you must show that your proposal is a good match with one of these topics. Please type below an exact copy of one or two paragraphs directly from the solicitation that you think best shows this match.Paragraphs from solicitation:* Planned Proposal Information All questions marked with a "*" are required for completion.Title of proposal to be prepared:*Estimate of grant dollars to be requested from federal agency for this proposal:*Name of Principal Investigator for this project:*Please list the names of any additional key personnel who will be assisting with the project:Name 1Name 2Name 3Name 4Name 5If more individuals are involved, please add their names here: Phase I Proposal title:*Phase I Principal Investigator first name:*Phase I Principal Investigator last name:*If this application is for assistance with an SBIR or STTR Phase II application, please provide specific information about the associated Phase I project:Phase I Project Start Date (format MM/DD/YYYY): MM slash DD slash YYYY Phase I Project End Date (format MM/DD/YYYY): MM slash DD slash YYYY Phase I Project TitlePhase I Award Amount:What were the technical objectives for this project?Briefly describe the results that were obtained.Briefly describe your interactions with the funding agency to date, explaining why you feel they will accept this application.* FMA Section II FMA SECTION II TEMPLATE Please download and complete the FMA Section II Template above. This must be completed and uploaded before submitting this online application. This section must be saved and converted to PDF format before being updated. There is a limit of 11 pages for this section and a maximum PDF file size of 1MB.Please upload your FMA Section II Template here:*Accepted file types: pdf, Max. file size: 1 MB. Budget for Preparing the Proposal Please fill out THIS BLANK BUDGET DOCUMENT. All relevant fields are required. Please upload it below when completed.Please upload your budget document here:*Max. file size: 512 MB.
