Business/Licensing Opportunity Form

*Indicates a required field

First Name*:

Last Name*:

E-mail Address*:

Phone*:

Note: E-mail or phone number is required.

Fax:

Company Name
or Other Affiliation:

Title and/or
Department:

Address 1*:

Address 2:

Address 3:

City*:

State/Province*:

--- Select State/Province --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Zip/Postal Code*:

Country:

Opportunity Being Offered to Wyeth

Nature of Opportunity:

Prescription Drug Product OTC Drug Product

Type of Opportunity*:

--- Select Type of Opportunity --- In License to Wyeth Patent License R & D Collaboration Divestiture to Wyeth Co-development/Collaboration Out License from Wyeth Interest to Acquire Wyeth Product

Compound or Technology ID
(name/number/designation):

Compound
or Technology Description*:

Other Business Opportunity Description
(if other than product/technology license):

For Product-related Opportunities, Specify the Following:

Therapeutic Area*:

--- Select Therapeutic Area --- Neuroscience Vaccines Metabolic Respiratory Hemophilia Infectous Disease Musculoskeletal Oncology Womens Health Cardiovascular Other

Primary Utility
or Disease Indications(s)*:

Route of Administration:

--- Select Route of Administration --- Oral Injectable (IV, IM, or SQ)

Stage of Development:

--- Select Stage of Development --- Discovery Stage or Not in Man Development Track Phase I Phase II Phase III NDA Filed NDA Approved Marketed Product

Territories Available for Partnering:

--- Select Territory --- Worldwide United States North America United States/Europe Europe Intercontinental Latin America Asia Pacific Rest of World (ex-United States)

Patent Status: