APPLICATION FORM INVENT

To apply for the incubation programme at IIM Calcutta Innovation Park, please fill the following information:

Name Of Social Enterprise:

Sector: (Mark YES in front of any ONE of the following; If ‘Others’, please specify): Agriculture, Food, Diary

Healthcare, Water and Sanitation

Technology and Development Education Housing Handicrafts Energy Microfinance/Financial Inclusion Others

Contact Details:

PRIMARY CONTACT PERSON (Should Be One Of The Full Time Founders)

Designation: Email:

Mobile Number:

Registered Address:

Office Address (if different from above)

Email

Office Phone

Website (if any)

Legal Status of firm: (E.g. Sole Owner/ Pvt Ltd / Partnership) Registration number and date: Firm registration (as applicable)

IIM Calcutta, Diamond Harbour Road, P.O. Joka, Kolkata - 700 104, India Phone: +91 33 2467 8300/8306, 2467 8313 | Fax: +91 33 2467 7174/7851/8062 | www.iimcip.org Reg. No. U74900WB2014NPL203219 | PAN No. AADCI6526M | TAN No. CALI04182D APPLICATION FORM INVENT

What problem are you trying to solve?

Describe your offering (product or service) with key features, Explain how it addresses the need

What is the social impact that your venture can generate? (Please support with numbers)

IIM Calcutta, Diamond Harbour Road, P.O. Joka, Kolkata - 700 104, India Phone: +91 33 2467 8300/8306, 2467 8313 | Fax: +91 33 2467 7174/7851/8062 | www.iimcip.org Reg. No. U74900WB2014NPL203219 | PAN No. AADCI6526M | TAN No. CALI04182D APPLICATION FORM INVENT

Who is/are the END CUSTOMERS? and why they would use your product / service?

Technology behind the core offering by the Start-up (tick applicable): To be developed Self Developed Acquired / Licensed Off the Shelf

If Self Developed – technology development time & linkages used / is the technology Patentable / status of patent and-or application / countries where applicable / if not yet patented what are the strategies for protection

If Acquired / Licensed – from whom & terms – conditions

If Off the Shelf – comments on the ‘innovation’ from the startup

IIM Calcutta, Diamond Harbour Road, P.O. Joka, Kolkata - 700 104, India Phone: +91 33 2467 8300/8306, 2467 8313 | Fax: +91 33 2467 7174/7851/8062 | www.iimcip.org Reg. No. U74900WB2014NPL203219 | PAN No. AADCI6526M | TAN No. CALI04182D APPLICATION FORM INVENT

Current Status

What is the current status of the business - ideation/ under development/ pilot launch/ revenue generation started etc .

Do you have paying Customers?

List your major customers / first adopters (if any)

Details of all Founders

SL No Name Educational Qualifications Work Permanent Contact: (Std. passed / Degree, Year, Experience Address Phone, Mobile, University) (Company, No. Email of Years, Functional Area)

IIM Calcutta, Diamond Harbour Road, P.O. Joka, Kolkata - 700 104, India Phone: +91 33 2467 8300/8306, 2467 8313 | Fax: +91 33 2467 7174/7851/8062 | www.iimcip.org Reg. No. U74900WB2014NPL203219 | PAN No. AADCI6526M | TAN No. CALI04182D