SAMPLE PARTNERSHIP APPLICATION
Note to applicants: Please complete all items relevant to the partner company/organization. If you are able to supply information about NASA’s goals and support/contributions, please include it. However, these items can be left blank and will be completed by NASA personnel after you submit this application.
1. Partner Information:
Proposed project: Informative title clearly identifying the partnership
Partner: Company/Organization Name
Contact Name
Address (include country)
Phone
Fax
For company/organization partner, indicate place of incorporation and name/address of any parent company. For individual partner, indicate citizenship
Organization Type: (e.g., domestic vs. foreign, private vs. public, corporation vs. partnership, etc.)
Small business under
37 CFR§404.3(c)? yes, no (select one)
Co./Org. summary: Describe the nature and type of your business
NASA: Mission Directorate or Organization Name
Contact Name
NASA Goddard Research Center
Mail Stop ____
Greenbelt, MD 20771
Phone
Fax
Other parties: Company/Organization Name
(if applicable) Contact Name
Address (include country)
Phone
Fax
Organization Type: (e.g., domestic vs. foreign, private vs. public, corporation vs. partnership, etc.)
Source: What prompted your initial contact (e.g., NASA Tech Briefs article, trade show presentation, Web site, referral, etc.)?
Continuation of existing effort? yes, no (select one; if “yes,” identify, if possible, (1) the contract, grant, cooperative agreement, or other instrument; (2) description of work done; and (3) terms of agreement(s). Note that the existing effort might be with a partner other than the NASA contact listed in this agreement.)
2. Project Summary:
Statement of Work: Summarize the effort
Milestones: List the key deliverables and phases
Schedule: Start date to end date (note that partnerships generally should not exceed 3 years) for each activity in schedule form (such as a Gantt Chart)
Partner’s Goals: A short description of what you want to accomplish in working with NASA
NASA’s Goals: A short description of what NASA wants to accomplish in working with you
Relevance to NASA: Indicate (1) the specific NASA mission or project for which this activity is required and/or (2) generally how NASA will benefit from the partnership
Follow-on anticipated: yes, no (select one; if “yes,” describe those efforts)
Software Involved: yes, no (select one)
3. Support/Contributions:
3.a From NASA:
Responsibilities: Indicate what NASA is expected to do under this project (be specific)
Funding: $X (or “none”)
Personnel time/effort: Staff name, position
civil servant, contractor (select one)
Grade level
Number of hours anticipated
Estimated travel material costs
Work to be performed at NASA, off-site (select one)
(or “none”)
Facilities: Indicate what NASA facilities will be needed (or “none”) and estimated cost of use
Equipment: Indicate what NASA equipment will be needed (or “none”) and estimated cost of use
Risks: Describe any potential risk that NASA may incur in the performance of this partnership (break or loss of equipment, destruction of facility due to fire, personal injury from equipment operation)
NASA Management: List NASA management that support this activity, including the principal investigator, project manager, and/or staff manager
Unique to NASA? Indicate whether NASA’s contributions are unique (i.e., developed in-house and/or not generally available on the commercial market from any source, including NASA contractors)
3.b From Partner:
Responsibilities: Indicate what you are expecting to do under this project (be specific)
Viability: Demonstrate that you have the expertise and financial viability to fulfill the above responsibilities
Funding: $X to reimburse NASA for its activities (or “none”)
Personnel time/effort: Staff name/type
Number of hours anticipated
Work to be performed at NASA, off-site (select one)
(or “none”)
Facilities: Indicate what facilities of yours will be used (or “none”)
Equipment: Indicate what equipment of yours will be used or provided to NASA (or “none”)
Risks: Describe any potential risk that partner may incur in the performance of this partnership (break or loss of equipment, destruction of facility due to fire, personal injury from equipment operation)
Expertise:
Other: Indicate any other contribution from you or other source (e.g., other federal government facilities/equipment) and, if from other source, the circumstances/vehicle by which that contribution is available to you
3.c Summary: X% from NASA and X% from partner (note: NASA expects at least a 50% contribution from its partners)
4. Data/Information Exchange:
4.a From NASA:
Information already provided by NASA:
Indicate type information, technology, software, or data and the source (or “none”)
Additional background information to be provided by NASA:
Indicate type information, technology, software, or data and the source (or “none”)
4.b From Partner:
Information already provided by partner:
Indicate type information, technology, software, or data and the source (or “none”)
Additional background information to be provided by partner:
Indicate type information, technology, software, or data and the source (or “none”)
4.c Partnership Results:
To be delivered to NASA:
Indicate type of reports and data to be delivered to NASA and for what purpose NASA will use the data now and in future (or “none”)
To be delivered to Partner:
Indicate type of reports and data to be delivered to Partner and for what purpose Partner will use the data now and in future (or “none”)
Disclosure of Information:
yes, no (select one. Indicate if results and partnership information can be disclosed to the public. If “no,” describe extent to which you would like the information to be protected and for what timeframe)
Company Representative:
Signature:______Date: ______
Name, Title
Phone, email
NASA Representative:
Signature:______Date: ______
Name, Title
Phone, email