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Task 1 Pre-Seed Application

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Task 1 Pre-Seed Application Powered By Docstoc
					    Task 1. Pre-Seed Application
Please answer ALL questions for your application to be considered.

A few things to keep in mind:
1. When you fill out the application, all of the information you enter is stored. However, if you wish to
go back to edit -- you must start from the very beginning of the application.

2. On some PCs the text may be small or difficult to read. If you press the "Ctrl" and the "+" keys the
text size will increase.

        General Company Information
        Where did you hear about this program?
Please help us by letting us know how you heard about this program.
   Online search
   CT Innovations/SBIR website
  Another website online
  Email blast from:
  Newspaper:
  Other Media:
  Other Agency:
  Other:
  Word of mouth

        1. Please provide the following information for the Company
        Corporate Official

Company Name

Title

Applicant Name

Date Company Legally Established

Street Address

City/Town
State

Zip Code

Office Phone

Cell Phone

Other Phone

Email Address

Website

        2. Type of Company
If you select other, please describe.
   C Corp
   LLC
   Partnership
   Sole Proprietorship
  Other

        3. Amount Applied For (Up to $150,000)
An amount in excess of $150,000 will cause the application to be rejected.



        4. SBIR Phase II Only
If you have won an SBIR Phase II after January 1, 2006 please indicate the contract number. Later you
will be asked to upload your SBIR Award Letter. (SBIR winners have their technology ALREADY
validated). This assumes the money you are applying for will be used to further the technology
developed on your SBIR project.
  SBIR Contract #

        5. Describe your technology area.
If you select Other -- please describe.
   IT
   Digital Media
   Medical Devices
   Photonics
   Advanced Materials
  BioTech
  Other

       6. Did the technology originate at a university?
  Yes
  No

       7. Was the technology licensed from a university?
  Yes (If yes, provide contact information)
  No

       8. What is your connection to Connecticut?
If other please describe.
   Connecticut Resident
   Employee of a Connecticut company
   Student at a Connecticut school
  Other

       9. How many employees does your company currently have?


       10. What percentage of your current employees are based in
       CT?
                    %

       11. Will 75% of employees be CT-based at the time of
       funding?
If no, please explain.
   Yes
  No

       12. Have you procured a 50% match of the amount you are
       applying for from private sources?
Definition of a Private 50% Match
Grants, loans or any type of funds from any federal or state sources, founders money or in-kind
services will NOT meet the 50% requirement for matching private investment funds. The investment
funds must also be totally new funds to the company and on terms at least the same or no more
favorable than the terms of our Pre-seed loan.
Without this match -- you cannot receive funding from this program. Individual
investors must use this template. click here
   Yes

     A. Technology/Product Overview
     A 1. What makes your technology/product unique?



     A 2. What problem does it solve?



     A 3. What is its value proposition?



     A 4. What industry(ies) does it serve?



     A 5. Describe the proprietary nature of your technology and
     how it is protected.



     A 6. What patents have been applied for or granted?



     A 7. Who owns the technology/product?
     A 8. What is the feasibility of the technology/product?



     A 9. Indicate the Technology Readiness Level of your
     technology/product in conjunction with the following TRL
     scale:
TRL = Technical Readiness Level
1 = Lowest, 9 = Highest
  TRL 1. Basic principles observed and reported
  TRL 2. Technology concept and/or application formulated
  TRL 3. Analytical and experimental critical function and/or characteristic proof of concept
  TRL 4. Component and/or breadboard validated in laboratory environment
  TRL 5. Laboratory scale: similar system validated in relevant environment
  TRL 6. Pilot scale: prototypical system validated in relevant environment
  TRL 7. Full scale system demonstrated in relevant environment
  TRL 8. Actual system completed and quantified through test and demonstration
  TRL 9. Actual system operated over full range of expected conditions

     B. Market Overview
     B 1. What is the target market for your technology/product?



     B 2. Who are the potential customers? Include any customer
     information you have gathered or developed.



     B 3. Provide any evidence or research substantiating the
     potential size of your target market.
B 4. List your existing or potential competitors and describe
any competitive advantage of your technology/product.
Attach any data that provides factual evidence of
competition. Quote any source that is used in your response.



C. Company Development Overview
C 1. How has your company been funded to date? Describe
any actual cash investments, indicating amounts, source of
funds and whether they came from private or public sources.
Indicate if the funds were from loans, grants, equity or other
sources.



C 2. Provide an historical timeline for working on your
technology/product. Indicate any significant milestones
achieved.



C 3. Provide a list of the key people involved in business
functions including names, titles and contact information.
C 4. Describe the key people involved in development of your
technology/product, including names, titles and contact
information.



C 5. Have any other people played important roles in the
company's development? Describe their involvement.



C 6. Describe your commercialization strategy, including
timeline and future milestones to achieve.



D. Personnel Overview
D 1. List the founders of the company and describe their
roles.



D 2. List key people involved in the project, including their
bios, relevant scientific, business and/or commercialization
experience and current positions.
    D 3. List any individuals potentially expected to join the
    company, including their roles, bios, and dates of arrival.



    D 4. Describe the current ownership of the company and any
    potential future owners.



    D 5. Indicate the current location and residence of the
    company's employees.



    E. Loan Funding - Up to $150,000
    E 1. How much funding are you applying for? Enter the
    dollar amount.
$

    E 2. List any funds received to date, describing the source,
    amount and terms.
         Source              Amount               Terms
      E 3. Describe how you intend to use the funds. Be as specific
      as possible. Include the amounts, Identify any vendors, and
      outcome/deliverable for each expenditure. Include the
      amount of resources needed to accomplish each goal/outcome
      as indicated below. Provide any additional documents such
      as a proforma and/or invoices. These may be uploaded at the
      end of the application.
Examples Of Fund Use (Proposed Expenditures):
Intellectual Property (IP) development, protection, accounting, legal
Technology assistance, review development
Business plan assistance
Marketing analysis
Prototype development
Consulting expenses
Startup Expenses
Hiring employees
Other (no more than 25% of budget)

Examples Of Improper Use of Funds
Reimbursement of prior loans, capital contributions or other investment in the Company
Payment or distribution to any founder, principal or owner of the Company
  Fund Use (Proposed Expenditures)            Budgeted $ Amount              Milestone Achieved




     E 4. Describe how financial assistance from Connecticut
     Innovations will result in potential job creation for
     Connecticut.
        E 5. I certify that no use of funds will be for ANY
        PREVIOUS EXPENDITURES. Please provide your
        electronic signature.
By submitting your name in the box below, you are authorizing ALL of the statements above.




        F. Acceptance of Terms of Financial Assistance
        F 1. Acceptance of Terms of Financial Assistance
a.    Loans are non-recourse with no immediate repayment of principal or interest. They will have a maturity and a balloon
     payment in 24 months.
b.    The interest rate will be 12% fixed, compounded monthly.
c.    The company is required to sign a “Connecticut Presence” clause for a minimum of three years.
d.    The company’s debt may not be prepaid without the express written consent of Connecticut Innovations.
     Failure to comply with (c) and (d) will require repayment at two times the outstanding balance.
e.    The company will provide CI with an option in its sole discretion to participate in an equity round of financing and
     convert its debt at a 25% discount at that time.

     By submitting your name in the box below, you are authorizing ALL of the statements above.




        F 2. Proceedings
Have any of the persons associated with this company been party to any criminal, civil, or
administrative proceedings, or charged with any offense other than a minor traffic violation? If yes,
please provide an explanation.
     Yes
     No

        F 3. Financial Considerations
Have any of the persons associated with this company been through bankruptcy, receivership or
compromise settlement? If yes, please provide an explanation.
     Yes
     No

        F 4. Civil Lawsuits
Have any of the persons associated with this company been party to or threatened with any civil
lawsuits of a meterial nature other than dissolution of marriage within the past five years? If yes,
please provide an explanation.
  Yes
  No

       F 5. Final Signature
ANY FALSE STATEMENT MADE HEREIN IS PUNISHABLE AS A CLASS A MISDEMEANOR UNDER SECTION
53a-157b OF THE CONNECTICUT GENERAL STATUTES

The undersigned acknowledges and consents to Connecticut Innovations, Inc., its successors and assignees to access
various sources of information it deems appropriate, but not limited to consumer credit reports, professional/personal
references etc. The undersigned by way of executing this form hereby agrees to hold harmless Connecticut Innovations,
Inc., its successors and assignees with respect to the procurement of any and all credit, character and financial
intelligence.

I certify that, to the best of my knowledge, the preceding information is true and correct and will report in writing to
Connecticut Innovations any changes to the information contained herein.

I further certify that I am a Connecticut resident and that my company is/will be established primarily in Connecticut.

 NO FEE OR A COMMISSION SHOULD BE PAID TO ANY 3RD PARTY FOR CONNECTICUT INNOVATIONS
 FUNDING. NO 3RD PARTY CAN INFLUENCE OR INCREASE THE BENEFITS AVAILABLE UNDER CI
 FUNDING. CONNECTICUT INNOVATIONS WORKS EXCLUSIVELY WITH ELIGIBLE COMPANIES, NOT
 WITH 3RD PARTIES.

APPROVAL OF PRE-SEED FINANCIAL ASSISTANCE IS NOT AN INDICATION THAT FUTURE
ADDITIONAL FUNDING WILL BE AVAILABLE FROM CONNECTICUT INNOVATIONS.

All fields must be completed and all questions answered for this application to be accepted.

By submitting your name in the box below, you are authorizing ALL of the statements above.


Signature

Date