<p> APPLICATION FORM INVENT</p><p>To apply for the incubation programme at IIM Calcutta Innovation Park, please fill the following information:</p><p>Name Of Social Enterprise:</p><p>Sector: (Mark YES in front of any ONE of the following; If ‘Others’, please specify): Agriculture, Food, Diary</p><p>Healthcare, Water and Sanitation</p><p>Technology and Development Education Housing Handicrafts Energy Microfinance/Financial Inclusion Others</p><p>Contact Details:</p><p>PRIMARY CONTACT PERSON (Should Be One Of The Full Time Founders)</p><p>Designation: Email:</p><p>Mobile Number:</p><p>Registered Address:</p><p>Office Address (if different from above)</p><p>Email</p><p>Office Phone</p><p>Website (if any)</p><p>Legal Status of firm: (E.g. Sole Owner/ Pvt Ltd / Partnership) Registration number and date: Firm registration (as applicable)</p><p>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</p><p>What problem are you trying to solve? <Describe the market need / gap that your product / service addresses> </p><p>Describe your offering (product or service) with key features, Explain how it addresses the need</p><p>What is the social impact that your venture can generate? (Please support with numbers)</p><p>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</p><p>Who is/are the END CUSTOMERS? and why they would use your product / service?</p><p>Technology behind the core offering by the Start-up (tick applicable): To be developed Self Developed Acquired / Licensed Off the Shelf</p><p>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</p><p>If Acquired / Licensed – from whom & terms – conditions</p><p>If Off the Shelf – comments on the ‘innovation’ from the startup</p><p>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</p><p>Current Status</p><p>What is the current status of the business - ideation/ under development/ pilot launch/ revenue generation started etc . </p><p>Do you have paying Customers? </p><p>List your major customers / first adopters (if any)</p><p>Details of all Founders</p><p>SL No Name Educational Qualifications Work Permanent Contact: (Std. passed / Degree, Year, Experience Address Phone, Mobile, University) (Company, No. Email of Years, Functional Area)</p><p>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</p>