Application Form for Innovators/Startup for availing As Institutions for the Start Ups/ Innovation scheme ‘SeNo Detail ‘Applicant Details I 2 3 For Innovators 1.0 | Innovator(Applicant’s) Name i 2. 3 1.00) _| Date of Birth: 10d) | Gender: Male 5 Female T1GHD | Profession: Student Business Person Professional Salaries Homemaker TI) _ | Tanovator Company Name (already formed) TID | Name of the Host Institution (under which Innovator is Working/plan to work) T2__ | Project Formation: Individual tC Group OO 13 | Address of Main Person if in case of Group) 14 | Contact No T 2 3 15 | Email D” T 2 3 1.6 | Ifthe Innovation Project is of Product: Process: Servicing 1.7__ | Field/Sector of the innovation project 18 _ | Give Brief Details/Description of Start Ups! Innovation Project/State key innovation. Features: 9 Hlas the project been started or yet to start? | I. Project yet to start If started, mention innovation Project Started |2. Project started on & Expected Date and Expected Duration: duration T.10 | Projected cost for start up/Innovation Project T1I | Amount incurred in the Project tl date: 1,12 | Expenditure required to be incurred:© For product realization (I) Marketing/Sales 1.13 _ | What kind of facilities do you need/expects T Library From the Host Institute? 2.Mentoring Services 3 Prototype Development 4 Facilities; Space; Internet; Laboratory ete. 5.Any other Services required(specify) 1.14 __ | What was the inspiration behind this idea? 1.15 | Why do you think that your idea/project/ Technology is innovative? Uniqueness about Your idea. Remarks: If Innovators have any PROTOTYPE/BUSINESS MODEL of the Unit/Product/Sample of their Innovative Idea they may present it in front of the Screening Committee of the Nodal InstituteRecommendations of Screenin; Committee for Innovator’s to availing Assistance under Host Institutions for the Start Ups/Innovation Scheme. Purpose of using this form is restricted only to the Members of the Screening Committee) Recommendations of Screening Committee: 10 ‘Student background: 1.0@) _ | Qualification of the Candidate T0GD | Experience: T0(mM) | Capability to fulfill the project: L.OCV) [Any other background iI Viability of the Project Technical Viability Economical Viability: 12 Estimated duration of the Project phase of the venture 13 Market Potential 14 ‘Assistance to be provided: T (like mentoring service, Prototype development, raw, | 2. material, other equipment usage, etc.) 3 4 5 15 Names of the members of Names Field Screening Committee L 2. 3 4 5 616 Recommendations of Screening Committee: (Product/Service usefulness (I) Uniqueness (I) Technology innovation (IV) Job-creation potential (VY) Market potential/scalability of the project (VD Impact on society/customer (VI) Current project status (VIM) Any other Specify: 17 ‘Assistance Required on the | Sustenance basis of the recommendations | Allowance: of the committee: Mentoring Services: Prototype development, raw material, etc. Total of assistance Required Remarks: If Innovators have any PROTOTYPE/BUSINESS MODEL of the Unit/Product/Sample of their Innovative Idea they may present it in front of the Screening Committee of the Nodal Institute.