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					1.
2. AFFORDABLE HEALTHCARE
   IN INDIA
3.
4. TRANSLATION AWARD -
   PRELIMINARY APPLICATION
5.
     PLEASE READ THE ACCOMPANYING INFORMATION FOR APPLICANTS AND THE
     WELLCOME TRUST'S FUNDING CONDITIONS IN CONJUNCTION WITH THIS
     APPLICATION FORM.


     Please return this form electronically and mark it ‘India Initiative’
     in subject heading to: techtransfer@wellcome.ac.uk


     USE OF YOUR INFORMATION
     The Wellcome Trust is committed to protecting the privacy of your personal information. Information that
     you supply in connection with this application and any funding arising from it will be treated in confidence,
     used for processing and evaluating your application, and will be stored by the Wellcome Trust, its agents
     and/or advisors in accordance with the Data Protection Act 1998. It may also be disclosed to external peer
     reviewers, some of whom may be based outside of the EU. The Wellcome Trust may publish basic details
     of successful awards, e.g. on its website or in its Annual Report, and contact you for your views on its
     funding schemes and application processes.

     Please contact the Wellcome Trust if you have any further questions about its policy on data protection.



     Principal Applicant

     Surname

     Forename(s)

     Title

     Position
     Employing
     organisation
     Address

     Telephone number(s)

     Email address


     Business Development/Technology Transfer Officer

     Surname

     Forename(s)



     Wellcome Trust Translation Award Preliminary Application
Position

Employing
organisation

Address

Telephone number(s)

Email address


1) Proposed project title




2) Please provide a summary of the technology to be developed (max 200 words).




3) Please give background details of a) key points that validate the technology, b) the data you
have generated to date including the current stage of development of the technology and c) any
other relevant information relating to your proposal.




4) Please provide details of the proposal, using the box below and including the following
(maximum of 4 pages):

(a) The plan of investigation proposed to be funded by the Trust including: the specific aims and
objectives; at least 2 milestones, for the Trust-funded component during the course of the project (funding
maybe dependent on achieving milestones); and how this proposal will ultimately lead to a healthcare
benefit.

(b) A Gantt chart or similar graphical overview of the tasks to be undertaken, their sequence and duration
for the entire project including those (marked separately) that will be undertaken in parallel but without
Trust funding (if applicable) and key development steps after Trust funding. What other funds (if any) are
contributing to related project tasks in the Gantt chart. Please give a brief description of the work to be
undertaken with these alternative funds.

(c) How the project will be managed to deliver the milestones and key objectives, describing in-house
expertise and any to be accessed externally.




5)

(a) Please provide details of the potential healthcare benefit of the technology.
1.
2. AFFORDABLE HEALTHCARE
   IN INDIA
3.
4. TRANSLATION AWARD -
   PRELIMINARY APPLICATION
5.
      (b) Please provide an outline of how the proposal will deliver a healthcare product or solution of
      particular relevance for India

      AND

      (c) Describe the following:
             i) Intended target population
              ii) Affordability
             iii) How you will enhance access to your healthcare product or solution including the
             delivery mechanisms




     6) COMMERCIAL MATTERS


     (a) Patent information (continue on another sheet if necessary)


     Application
     number:



     Priority date:



     Inventors:



     Applicant:



     Funding source:



       Title




(b)       How do these patent(s) or patent application(s) relate to the proposal?




      Wellcome Trust Translation Award Preliminary Application
         Describe any freedom to operate issues that have been identified or that might arise and how
(c)      these will be or have been addressed. Include the type and date of any searches that have
         been conducted.




         Describe any new types of intellectual property that can be anticipated including how the
(d)
         identification of these inventions will be managed.




      7) Please describe the competitive advantage of the proposed technology over current
      approaches.



      8) Please describe why at the end of Trust funding the technology will be attractive for follow on
      funding or investment, be subject to a commercial exit or attractive to a government or non-
      governmental organisation health provider and how this will be achieved.




      9) Please identify parties that would be interested in such a technology and any approaches made
      to these to date.




      10) Please provide an approximate budget for the project in INR and GBP£ (please state the
      conversion rate and date used)

      INR/GBP£:                              Conversion rate:                     Date:



      11) If this is a resubmission of a project to the Translation Award scheme, please provide details
      of the key differences between that application and the current proposal.



      12) For company applicants, please indicate whether your company has publicly tradable shares,
      the stock exchange(s) where it is listed and the total market capitalisation of the relevant
      company.




      13) Please detail where you initially heard about the Affordable Healthcare in India initiative (pick
      one category)


      Technology Transfer Member of Staff    Presentation       Advertisement   Wellcome Trust website
      Other website Colleague     other – please specify

				
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