Title: 1 PERSONAL DETAILS

Surname:

First

Name(s):

Contact Address: Home Address (if different):

House House Name/Number Name/Number Street Street

Town Town

County County

Postcode Postcode

Home Telephone Number:

Mobile Telephone Number:

Email Address:

Date of Birth (dd/mm/yyyy): / /

Name of University: Course Title / Year of Study/ Year / Yr / Yr of Graduation: Student Number:

Nationality:

Do you require a permit to work in the UK? Yes No

If you are unsure of your need for a permit to work contact us for advice.

How did you hear about BSEEN?

ERDF-2007-13 This project is part funded by ERDF ERDF-BSEEN-2012-10-03

2 YOUR IDEA

Please define your business idea (150 words maximum):

Who/what is your target market?

What research have you done already to prove the need for your product/ service?

Why is your product/ service different from what is already in the marketplace?

What aspects of your business do you consider to be innovative?

ERDF-2007-13 This project is part funded by ERDF ERDF-BSEEN-2012-10-03

What are your start-up costs and how do you intend to source that money? What will the monies mainly be spent on?

How do you intend to generate revenue for the business?

Describe how your business will benefit the local or/and UK economy?

What do you see as the main difficulties in getting started?

What equipment or facilities do you think you will need?

I confirm that I have not registered the business or started trading yet (please tick)

ERDF-2007-13 This project is part funded by ERDF ERDF-BSEEN-2012-10-03

I anticipate/would like to begin trading in:

1-6 months 7-12 months Over 12 months

3 ABOUT YOU

What is your motivation for applying to the BSEEN Programme?

Describe the skills you possess which you believe will help you to progress your idea into a viable business.

What previous experience have you gained that would help you in business?

Where do you see yourself in 5 years time?

ERDF-2007-13 This project is part funded by ERDF ERDF-BSEEN-2012-10-03

What are your expectations of the BSEEN Programme in terms of support, time and benefits to you?

If your application was successful, which incubator unit would you prefer to be based at?

Aston University Birmingham City University University of Birmingham

Please explain your choice.

4 BUSINESS SUMMARY

If you feel it may be beneficial to your application, you may attach additional information about your business idea, for example a business plan or financial forecasts.

If your idea is not quite fully developed and would like further information on how to put together a business plan, please indicate in the box provided.

5 DIVERSITY MONITORING INFORMATION

The BSEEN project attempts to provide equality of opportunity throughout its selection process. In addition we are required to provide statistical information about our beneficiaries to the Funding Agency (ERDF). In order to comply with this requirement and to be able to monitor the effectiveness of our diversity policies we ask you to complete the following information. The information you provide here will be treated in total confidence and will have no affect on your application. Thank you for your co-operation.

Do you have any long-term illness, health problem or disability, which limits your daily activities or the work you can do?

Yes No

ERDF-2007-13 This project is part funded by ERDF ERDF-BSEEN-2012-10-03

6 ETHNICITY

What is your ethnic group?

A - White B - Mixed C - Asian  White  White and Black Caribbean  Asian British  British  White and Black African  Indian  European  White and Asian  Pakistani  Any other White  Any other Mixed background  Bangladeshi background (please write below)  Any other Asian (please write below) background (please write below)

D - Black E - Chinese F - Other  Black British  Chinese British  Any other background  Caribbean  Chinese (please write below )  African  Any other Chinese  Any other Black background background (please write (please write below ) below)

DATA PROTECTION

The information that you provide on this form will be available to: University Project and Finance staff involved in the management of BSEEN including any external auditors appointed by Project staff; the regional agency, Department for Communities and Local Government (DCLG) and its auditors, and auditors appointed by the European Commission. You agree that your personal information may be used for evaluation purposes and to participate in any evaluation exercise carried out by the Funding Agency or an external consultant.

Please tick here to confirm that you have read and understood the above conditions.

Signature:

Date:

ERDF-2007-13 This project is part funded by ERDF ERDF-BSEEN-2012-10-03