QPI CONTACT FORM

First Name

Last Name

EMail Address

Phone Number

Please choose the options that best describes you: (Choose all that apply)

Affiliated with a company that is interested in developing a relationship with Queen'sAffiliated with other external organizationAffiliated with Queen's University

Company Info

What is the name of your company?

What is your companies website URL?

What is your role within the company?

Where is your company located?

City

Province/State

Country

Tell us briefly about your company:

Tell us about your objectives related to your interest in learning about Queen's programs for Partnerships and Innovation.

Contact Information

None	Alumnus/Alumna
Faculty Member	Graduate Student (Masters or PhD)
Adjunct Faculty Member	Medical Resident
Emeritus Faculty Member	Post Doctoral Fellow
Staff	Undergraduate Student
Volunteer	Other