国家卫生研究院技术移转企划书

1、附件二機密國家衛生研究院技術移轉企劃書National Health Research Institutes Technology Transfer Proposal壹、 基本資料 (A. Information about Applicant) 非專屬授權 (Non-exclusive License) 專屬授權 (Exclusive License)申請日期：中華民國 年 月 日Filing Date: _ _ /_ _ /20_ _（公司）公司名稱Name of Company成立日期Date of Incorporation（公司）英文名稱Name of Company in Engl

2、ish資本額Capital amount負責人Name of Companys Licensing Representative去年度營業額Gross Turnover in 2009工廠登記編號Registration No. of Factory 公司地址Address of Company聯絡住址Mailing Address of Company電話Telephone No.E-mail 傳真Fax No.員工人數Number of Employees研發人員人數Number of Employees in R&D立約代表人Authorized Representative o

3、f the License Agreement職稱Title本案聯絡人Contact Person of this Application職稱Title聯絡電話Telephone No. of Contact PersonE-mail of Contact Person聯絡傳真Fax No. of Contact Person檢附資料Required Attachments營運計畫書(Business plan or operation plan)公司設立變更登記影本(用印公司大小章) (Photocopies of the Companys Incorporation Approval do

4、cument)*All the above documents must be endorsed officially by the company with signature or company seal.請仔細研讀以下問題並據實勾選以表聲明(Please read the following questions carefully and provide answers accordingly)：1. 本公司為依法登記且二年內無違法紀錄，並從事或即將從事與計畫內容或技術性質相關業務者 (The company was incorporated and approved by law a

5、nd does not have any record of misconduct or conviction for any offense within the past two years and is either engaged in or is about to engage in business related to the utilization of the licensed technology.) -是(Yes) 否(No)2. 本公司有依法繳交營利事業所得稅 (The company filed and paid the Profit-seeking Enterpri

6、se Income Tax regularly.) -是(Yes) 否(No)（請妥善保存相關資料，以供本院應主管機關要求備查。Please keep relevant information for future reference in case of need.）3. 與本院重大關係紀錄 (If any, please list any prior collaboration or similar relationship with NHRI in below table.)日期 本院聯絡人 洽詢/委託/合作/技轉研究項目Date NHRI Contact Person Inquiry/

7、Commission/Collaboration/Patent Licensing/ Technology transfer_ _ _ _ _ _ _4. 重要產品/營業額(請附產品目錄及產品說明書一份) (Description of your leading product(s) and related net sale(s). Please use additional paper and attach product catalogue(s) and product instruction(s).) 5. 單位組織架構 (請以簡單圖表表示) (Organization chart -

8、please use a simple diagram.)6. 開發、生產銷售等大事紀 (Companys highlights on R&D, production, sales and marketing.)(民國)年 (Year) 事件說明 (Description of Event)_ _ _ _7. 關係企業/協力廠(請選擇性提供，有助於內部審查) (List any Affiliate/ Third parties. Please provide the information selectively; it would serve as part of the found

9、ation for licensing decisions.)產品(Product(s)：貳、 現況與計畫(包含技轉名稱、預期用途、技術移轉步驟及達成時間、後續發展及及後續投入等; 如不敷使用，請自行以A4紙加頁)B. The Current Situation and Plan (include the name and description of product(s) or method(s) to be developed with the licensed technology and, for each product or method to be developed, a de

10、scription of expected product use and development programs, including (where relevant) major preclinical, clinical, regulatory, manufacturing and marketing stages; monetary and personnel commitments for each development stage; and the projected time to accomplish each stage of commercial development, etc. Please attach separate paper if more space is needed.)I certify, to the best of my knowledge, that all of the information provided on this application and