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You are submitting to the Prix Galien UK Awards. If you are interested in submitting in another country, kindly make your choice in the selection drop-down from the login screen.

Thank you for applying for a Prix Galien Award. We urge you to provide the most accurate and up-to-date information possible for your product/candidate submission. The following aspects are particularly important:

Please address the specific question in the each section – be as specific as possible
Please be aware of the word limits in each section
All sections are mandatory (except where indicated)
The judging committee will only take into account information you provide on the form, and will not conduct wider searches
Any references you provide should be specific to the product/solution

Select a category of submission *

Prix Galien StartUp 2023 Application Form

GENERAL INFORMATION

Company Name *

Product/Solution Name *

Generic Name

Date of MHRA Approval in the UK
(if not licensed please provide details of when the license is expected you can also provide details of approvals in other countries)

Date of Approval in the UK, including the name of approving body(ies)
(including CE/UK CA marking. If not approved, please provide details of when this is expected (you can also provide details of approvals in other countries (100 words maximum)*

Details of MHRA Approvals (100 words maximum)

words remaining :

Therapeutic Indications
(if appropriate, otherwise add N/A):

Please provide details of public sector funding, and public sector involvement, that has made this innovation possible
(250 words maximum)

words remaining :

Licensed Therapeutic Indications
(please include the therapeutic indication from the SmPC)

Indications for the product
(please be as specific as possible):

Has the product been approved by NICE or any other body in the UK
(for NICE approval, please provide date. If not approved by NICE, or approval is pending, please provide details).

Has the product been approved by NICE or any other Governmental body in the UK
(if this does not require such approval, please state reasons why).

Has this product / Innovation previously received a Prix Galien award in the UK or in any other country
(please provide details including dates)

Has the product received any other award in the UK or in any other country?

BACKGROUND

Background information and need
(please be as specific as possible in your description; limit 500 words)

words remaining :

Development & Clinical Or Preclinical Evidence (500 words)

History and timeline for the development of the product including preclinical and clinical evidence
(please be as specific as possible in your description; 500 words)

words remaining :

Provide technical details where appropriate
(for example, interoperability, data security, etc; 250 words maximum)

INNOVATION

Why is this drug or device innovative, and/or how it will improve the human condition, and/or why is it better than competitor products
(500 words)

words remaining :

REFERENCES

Please provide references specific for your product
(ideally this should be from peer-reviewed literature, or papers in press, but if this is not possible, please provide other sources and justify their inclusion)

Upload a maximum of two other documents specific for your product (if necessary).

*Clearly label your files with asset name followed by product and company name.
Please ensure uploaded files are in PDF format.
Kindly ensure file size does not exceed 10mb.

Gold Contributor
Package

Product Entry

Dedicated Table of 10 at the Awards Ceremony

5 Tickets to the Galien Forum

£23,500

Silver Contributor
Package

Product Entry

5 Tickets to the Awards Ceremony

3 Tickets to the Galien Forum

£15,000

Bronze Contributor
Package

Product Entry

2 Tickets to the Awards Ceremony

2 Tickets to the Galien Forum

£9,000

	10 additional tickets to the Awards Ceremony		£13,500
	Individual combo ticket to the Awards Ceremony and Forum		£1,450
	Individual Award Ceremony ticket		£1,450
	Individual Forum ticket		£550

Proceed to Payment

You have chosen to settle your fees through Business France. Please contact Roxane: roxane.valfort@businessfrance.fr to complete your submission

Bank Name:	JP Morgan Chase Bank
Branch Name:	Broadway Morris Exchange 294
Address:	42 Broadway, New York, NY 10004
ABA/routing number:	021000021
Account number:	515907223
Account name:	The Galien Foundation

Account information for payment by wire transfer

Please be sure to upload your transaction receipt to complete your submission

Submission Validation

Please review before validating your submission to be an official contender for the Prix Galien. Submission validation allows you to amend text and uploaded documents until the submission closure date posted in your dashboard but not to withdraw your submission.

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Select a category of submission *

Submission Public Sector Category

Gold Contributor Package

Silver ContributorPackage

Bronze ContributorPackage

10 additional tickets to the Awards Ceremony

Individual combo ticket to the Awards Ceremony and Forum

Individual Award Ceremony ticket

Individual Forum ticket

Submission Validation

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Submission
Public Sector Category

Gold Contributor
Package

Silver Contributor
Package

Bronze Contributor
Package