Application of Entrepreneur/Incubatee

1. APPLICANT INFORMATION

A) Applicant's(entrepreneur) Name:

B) Age:

C) Educational Qualification:

D) Postal Address:

E) Telephone/Mobile

F) Fax:

G) Email:

H) Website (if any):

I) Current professional/employment status

2. COMPANY INFORMATION

A) Have you registered a company, give details:

B) Name of applicant company/firm:

C) Location from which company is operating:

D) Relationship with the Business Incubator/Host Institute:

E) Company Sector (Manufacturing / Service):
ManufacturingService

F) Investment in Plant & Machinery (Manufacturing sector) / Investment in equipments (Service sector):

G) Company Type:
MicroSmallMedium

3. PROJECT INFORMATION
A Details of Proposed Idea/Innovation

A1) Title of the technology/innovation:

A2) Category of technology/innovation (specify process/product/new application/other):

A3) If the idea involves the use of existing intellectual property, give details of the owner of the same and
arrangements of sourcing the innovation and terms of its commercialization:

A4) Specify the potential areas of application in industry/market:

A5) Specify newness/uniqueness of the innovation (better performance/new features/improvements):

A6) What is already available in the market? What is the market potential?. What value it would add in the market:

B. Current Development Status of Innovation

B1) What is the current development status of the innovation/product or service offerings? (Whether still an idea or ready to launch):

B2) Idea readiness level:

B3) Specify the time period in months required for innovation to be completely developed for field testing/ ready for intended end-user?:

C. Financial Requirements

C1) Do you have a business plan for taking innovation from lab to market? (Attach Business Plan):

C2) What level of funding is required for making innovation market ready?:

C3) Please give activity-wise break-up (Activities include design/prototype development/lab/bench scale
production/professional services/hiring staff/trials/test marketing/miscellaneous: (Upload File)

4. OTHER RELATED INFORMATION

A) Are there any team members/partners and mentors/guides in your innovative project. If so give name and
complete contact address with phone and e-mail):

B) Information on Patents filed/granted (if any):

C) Any awards or recognition related to the innovation:

D) Please include any further information that you wish to communicate to us to help us in judging your
application:

I declare all the information provided is true.