CONFIDENTIAL
For internal use
QUANTUM LEAP PROGRAM 2015
File # : [Keywords]
PHASE 1 APPLICATION (LETTER OF INTENT)
This form must be filled in with “Arial 11” font, typed at 1.15 line spacing
Total Amount of the Project
Amount Requested from CDQM [Amount]
Amount Requested from Alsace
or Rhône-Alpes
TITLE OF THE PROJECT (In English)
[Title]
IDENTIFICATION OF THE PRINCIPAL INVESTIGATOR (PI)
Last name:
First name:
Private Organization or
University/Department:
Address:
City:
Country:
Province:
Postal code:
Phone #:
Ext:
Email:
IDENTIFICATION OF THE PRINCIPAL INVESTIGATOR (PI) (Alsace or Rhône-Alpes)
Last name:
First name:
Private Organization or
University/Department:
Address:
City:
Country:
Province:
Phone #:
Postal code:
Ext:
Email:
Québec-France/Phase I Application form 2015
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CONFIDENTIAL
AMOUNT REQUESTED:
TITLE OF THE PROJECT:
[Comments]
CQDM FILE #:
[Keywords]
[Title]
IDENTIFICATION OF THE RESEARCH GROUP (PI AND THE CO-INVESTIGATORS) (including those from
private organizations). Add lines if necessary
Name
Affiliation
Email address
Discipline
Contribution to the project
1
PI
2
3
4
Québec-France /Phase I Application form 2015
Page 2 of 5
CONFIDENTIAL
AMOUNT REQUESTED:
TITLE OF THE PROJECT:
[Comments]
CQDM FILE #:
[Keywords]
[Title]
SECTION 1. PROJECT SUMMARY (maximum 1 page)
Define the following aspects of your project: background information, current state of the technology, objectives,
experimental approach and brief research plan.
Québec-France /Phase I Application form 2015
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CONFIDENTIAL
AMOUNT REQUESTED:
TITLE OF THE PROJECT:
[Comments]
[Keywords]
CQDM FILE #:
[Title]
INSTRUCTIONS: PLEASE REFER TO THE INSTRUCTIONS ON THIS PAGE TO COMPLETE SECTIONS 2 to 5,
WITH A MAXIMUM OF 2 PAGES TOTAL.
SECTION 2. PROJECT DELIVRABLES
The deliverables are the concrete, tangible work products resulting from the completion of the project, and they are not
to be confused with milestones that indicate important steps toward completion of the project.
Define the tangible assets that will result from your work and its intended use in the drug R&D process. Explain how
and in what form the deliverables may be transferable to the industry for their use in biopharmaceutical research.
SECTION 3. IMPACT ON DRUG R&D
Select which main step(s) of the drug discovery and/or development process your project is most likely to impact:
Target identification
Discovery / screening
Lead optimization
Preclinical studies
Clinical development
What gap in the pharmaceutical research and development process is the project trying to resolve?
Describe how the technology is aligned with pharma needs and how it will improve, enhance or accelerate the drug
R&D process.
If applicable, describe the impacts on:
o Opening new therapeutic approaches and research avenues
o Bringing more effective medicines to the clinic and to the market
o Increasing the efficacy of existing drugs
o Reducing R&D costs, time to market or decreasing the risks of development and attrition rate
o Other impacts on the drug discovery and development process
SECTION 4. INNOVATIVE CHARACTER OF THE TECHNOLOGY, POSITIONING AND INTERNATIONAL
COMPETITIVENESS OF THE PROJECT
Describe the novelty and the originality of the technical approach and explain how the proposed research represents a
major breakthrough or a significant improvement with respect to existing technologies (or in development) worldwide;
describe the added value of the technology with regard to future potential applications and the international competing
technologies used to achieve similar readout or goals.
SECTION 5. TEAM COLLABORATION and COMMERCIAL OPPORTUNITIES
TEAM:
Discuss the role of the PIs and co-investigators in the achievement of the research.
Discuss the synergies and complementarities of the team.
If the researchers are affiliated to a private organization, provide some corporate information. Describe how the
organization is qualified in relation to the achievement of the research;
POTENTIAL COMMERICIAL VALUE:
Outline the commercial opportunities your technology will yield in the biopharma R&D sector.
Describe the technical development plan that would be required to commercialise the technology (manufacturing,
scale-up, regulation, foreground and background IP, etc.), including a brief tentative timeline.
For SMEs involved in this project, briefly discuss how will funding of this project will create synergistic value for your
organization and how is the project aligned with corporate goals and business plan.
Québec-France /Phase I Application form 2015
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CONFIDENTIAL
AMOUNT REQUESTED:
TITLE OF THE PROJECT:
[Comments]
CQDM FILE #:
[Keywords]
[Title]
SECTION 6. PRINCIPAL INVESTIGATOR’S SIGNATURES
1. I authorize CQDM to exchange all information in relation to my file for evaluation purposes, under the condition
that the confidential character is respected by the individuals who are given access to this information.
2. I obtained the agreement from all the co-investigators to participate in this research project.
3. I certify that all information provided in this application is complete and accurate to the best of my
knowledge.
Signature
(Canada) :
Date :
Name :
Signature
(France) :
Date :
Name :
Québec-France /Phase I Application form 2015
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