第1页共4页编号：时间：2021年x月x日书山有路勤为径，学海无涯苦作舟页码：第1页共4页國家衛生研究院技術移轉企劃書NationalHealthResearchInstitutesTechnologyTransferProposal壹、基本資料(A.InformationaboutApplicant)□非專屬授權(Non-exclusiveLicense)□專屬授權(ExclusiveLicense)申請日期：中華民國年月日FilingDate:__/__/20__（公司）公司名稱NameofCompany成立日期DateofIncorporation（公司）英文名稱NameofCompanyinEnglish資本額Capitalamount負責人NameofCompany’sLicensingRepresentative去年度營業額GrossTurnoverin2009工廠登記編號RegistrationNo.ofFactory公司地址AddressofCompany聯絡住址MailingAddressofCompany電話TelephoneNo.E-mail傳真FaxNo.員工人數NumberofEmployees研發人員人數NumberofEmployeesinR&D立約代表人AuthorizedRepresentativeoftheLicenseAgreement職稱Title第2页共4页第1页共4页编号：时间：2021年x月x日书山有路勤为径，学海无涯苦作舟页码：第2页共4页本案聯絡人ContactPersonofthisApplication職稱Title聯絡電話TelephoneNo.ofContactPersonE-mailofContactPerson聯絡傳真FaxNo.ofContactPerson檢附資料RequiredAttachments□營運計畫書(Businessplanoroperationplan)□公司設立\變更登記影本(用印公司大小章)(PhotocopiesoftheCompany’sIncorporationApprovaldocument)*Alltheabovedocumentsmustbeendorsedofficiallybythecompanywithsignatureorcompanyseal.＊請仔細研讀以下問題並據實勾選以表聲明(Pleasereadthefollowingquestionscarefullyandprovideanswersaccordingly)：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(Thecompanywasincorporatedandapprovedbylawanddoesnothaveanyrecordofmisconductorconvictionforanyoffensewithinthepasttwoyearsandiseitherengagedinorisabouttoengageinbusinessrelatedtotheutilizationofthelicensedtechnology.)---------□是(Yes)□否(No)2.本公司有依法繳交營利事業所得稅(ThecompanyfiledandpaidtheProfit-seekingEnterpriseIncomeTaxregularly.)--□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。Pleasekeeprelevantinformationforfuturereferenceincaseofneed.）3.與本院重大關係紀錄(Ifany,pleaselistanypriorcollaborationorsimilarrelationshipwithNHRIinbelowtable.)日期本院聯絡人洽詢/委託/合作/技轉研究項目DateNHRIContactPersonInquiry/Commission/Collaboration/PatentLicensing/Technologytransfer__________________________________________________________________________________________________________________________________________________________________第3页共4页第2页共4页编号：时间：2021年x月x日书山有路勤为径，学海无涯苦作舟页码：第3页共4页4.重要產品/營業額(請附產品目錄及產品說明書一份)(Descriptionofyourleadingproduct(s)andrelatednetsale(s).Pleaseuseadditionalpaperandattachproductcatalogue(s)andproductinstruction(s).)5.單位組織架構(請以簡單圖表表示)(Organizationchart-pleaseuseasimplediagram.)6.開發、生產銷售等大事紀(Company’shighlightsonR&D,production,salesandmarketing.)(民國)年(Year)事件說明(DescriptionofEvent)______________________________________________________________________________________________________________________________________________________7.關係企業/協力廠(請選擇性提供，有助於內部審查)(ListanyAffiliate/Thirdparties.Pleaseprovidetheinformationselectively;itwouldserveaspartofthefoundationforlicensingdecisions.)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.TheCurrentSituationandPlan(includethenameanddescriptionofproduct(s)ormethod(s)tobedevelopedwiththelicensedtechnologyand,foreachproductormethodtobedeveloped,adescriptionofexpectedproductuseanddevelopmentprograms,including(whererelevant)majorpreclinical,clinical,regulatory,manufacturingandmarketingstages;monetaryandpersonnelcommitmentsforeachdevelopmentstage;andtheprojectedtimetoaccomplisheachstageof第4页共4页第3页共4页编号：时间：2021年x月x日书山有路勤为径，学海无涯苦作舟页码：第4页共4页commercialdevelopment,etc.Pleaseattachseparatepaperifmorespaceisneeded.)Icertify,tothebestofmyknowledge,thatalloftheinformationprovidedonthisapplicationandonattachmentstothisapplicationistrueandaccurate.代表人（簽章）：SignatureofApplicantorAuthorizedRepresentativeDate申請單位(用印)：___________PrintName代表人職稱：______________Title填表日期：年月日
