Partnering Opportunity Submission Form

*Mandatory field

First Name *

Last Name *

Name of Company / Institution *

Company / Institution web address (if any)

Company / Institution Address

Zip Code

City

Country

Telephone

E-mail address

Offered Opportunity *

1. Nature of Opportunity Compund Product Technology

2. Development Phase Marketed Approved Registration phase Phase III Phase II Phase I Preclinical

3. Therapy Area Asthma/COPD Cardiology Central Nervous System Disorders Critical Care / ICU setting Oncology Pain Urology Other (please specify below)

4. Is there Intellectual Property protection available or filed for the opportunity? * Yes No

5. If so, what kind? * Composition of matter Formulation Use Process Data exclusivity No protection

6. What markets are covered by the patents / protection?

7. Is clinical data available? * Yes No

If so, at what phase? *

8. What other data is available?

9. How widely is the opportunity available for licensing (geographies, indications)? *

10. Please describe for us what the benefits of the opportunity are compared to the conventional therapies. Please also describe the proposed structure for the collaboration, if Orion were to pursue it further.

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