Applicant Info:

Firstname:
Lastname:
Email:
Phone:
Mailing Address:
City:
State:
ZipCode:

Project Info:

Project Title:
Organization:
How long has your organization, group or program been in existence? If you are an individual applicant, how long have you been working in this field?:
App Type:	Organization Individual

Problem/Solution/Impact:

When completing the remaining portion of the application form please use the following outline for comprehensive answers.(Note: Cut/paste your responses into the boxes below.)

1. Problem
2. Solution
3. Impact

What serious problem or challenge with broad significance does your technology address? Explain the context in which your technology operates.
Solution Category:	Science Medicine Technology
Please describe your technology, or novel application of an existing technology, with emphasis on the innovations that you have contributed. How is your new technology or application distinctive from previous solutions addressing the same or similar problems?
What impact has your technology had on the relevant problem in the field? Who and how many people have benefited and how? Note: Please present evidence from credible sources to support the claimed impact. If there are negative consequences, please address these by discussing how you have or plan to deal with these issues.
What is the potential for this technology to be used to serve more people? If you have plans to ramp up or expand the project, please explain.
Could your work be a model for others to pursue? Could this technology be put to use in other places or situations?
Are there others who should be acknowledged and appropriately referenced? Please List.
Have you participated in conferences where your work has been highlighted?
Briefly describe how the cash prize will be used if you are chosen to receive the award?
Please provide a 75 word profile of your technology as you would like it to appear in collateral materials.