2024 MIX Affiliate Program Application Form

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Thank you for your interest in the MIX Affiliate Program. Applications will be reviewed on a rolling basis and space will be offered as it becomes available.

The MIX Affiliate Program is geared towards companies who aren't physically located at MIX, but who would still benefit from the programs and mentorship that MIX offers.

Requirements to become an Affiliate member include:

•Must be domiciled in Canada

•Be at either the growth stage or nearing the growth stage *exceptions apply

•Fully executed Affiliate Membership Agreement outlining expectations, roles and responsibilities

•Annual membership fee (some discounts apply)

•Active participation in MIX mentorship and programs *This means you and/or your team members should be actively participating in mentorship activities, events, VIP tours etc. Programs are open to all employees of Affiliate Companies.

Application process:

1) Applicants complete and submit an application form.

2) Applications will be reviewed by our internal Screening Committee.

2) Successful applicants will be brought in for in-person interviews with our Selection Committee.

3) If you are selected for the Affiliate Program, we will reach out with the details regarding next steps.

If you have any questions, please contact Elliot Fung at elliot@medicalinnovationxchange.ca

Email *

Date *

YYYY

What is the name of your company *

What is your website *

Name, email and role of applicant *

How many years has the company been active *

Is the company based in Ontario? *

Yes

How many employees does the company currently have? *

Please provide a brief description of what the company does. *

Has the company been enrolled as a member or client (current or former) of any Ontario-based incubators, regional innovation centre or accelerators? If so please indicate which ones. *

Please describe the stage at your company is in, including the maturity of your product. *

Please indicate the last fundraising round that you completed (Seed, Series A, Series B etc.) *

Pre-Seed

Seed

Series A

Series B

Series C

Bridge

Other

Why would you like to join MIX as an Affiliate Member? *

Send me a copy of my responses.

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