Golden Jubilee Biotech Park for Women Entrepreneurship Opportunity

GOLDEN JUBILEE BIOTECH PARK FOR WOMEN SOCIETY Please complete the enclosed form and send to:

General Manager Golden Jubilee Biotech Park for Women Society Inside SIPCOT IT Park Navallur, Old Mahabalipuram Road Kanchipuram District – 603 103 Phone: +91-9840098371 (Office) Mobile: +91-7305621230 (Bio-Incubation Centre) Email: GM@biotechpark.co.in; support@biotechpark.co.in Website: www.biotechpark.co.in

Kindly note than this application duly filled-in along with the non-refundable processing fee of Rs.1000/- (Rupees One Thousand Only) in the form of Demand Draft in Favor of “Golden Jubilee Biotech Park for Women Society” payable at Chennai.

GOLDEN JUBILEE BIOTECH PARK FOR WOMEN SOCIETY Application of the Entrepreneur/Incubatee I.

Applicant Information 1. Applicant (woman entrepreneur) name:

2. Contact details (Address, Phone, Fax, Email, website if any): 3. Date of Birth: 4. Professional Qualification: II.

5. Current professional/employment status: Company Information

1. Have you registered a company? give details: 2. Name of applicant company/firm:

3. Location from which company is operating (if applicable): 4. Company Sector (Manufacturing/services):

5. Major of domain of activity (Health care/Medical.):

6. Investment: in plant machinery (for manufacturing sector/ in equipment) 7. (for services sector) 8. Nature of activities proposed:

9. Indicate the proposed number of manpower (pro women):

10. Category of Biological/Chemical materials to be used – Annex

11. Nature of the samples – hazardous/biodegradable/non-biodegradeable: 12. Level of safety being proposed to be adopted both chemical/biological:

13. List of major equipment needed/to be installed/power requirement Annex 14. List of special facilities needed/to be installed– Clean room/Cold room /Biosafety hoods/Fume hoods etc: 15. Any special infrastructure requirement:

16. Nature and quantity and constituents of effluents to be generated: 17. Indicate the proposed treatment methods:

18. Indicate the approximate water consumption per day: 19. Indicate the period of operation per day:

20. Does the scientific activity involve the application of radioactive materials?

21. Indicate the emergency and safety measures which will be adopted:

III.

22. Regulatory and statutory approvals: Project information

1. Details of proposed idea/innovation (will be kept confidential): Annex

2. Title of the technology innovation:

3. Category of technology/innovation application/other):

(specify

process/product/new

4. Using existing intellectual property, give details of the owner and arrangements of sourcing: 5. Specify the potential areas of applications in industry/market: 6. Specify the uniqueness:

7. Market info – available/potential/:

8. Current development status -Technology readiness level:

IV.

9. Time required

Financial Details 1. A business plan

V.

2. Cost of the Project and how it is being met Other related information

1. Are there any team members/partner and mentors 2. Contact info

3. Patents if any

4. Awards if any I,…………………………………………………………………………, here by certify that the information furnished in the application form is true, complete and best to my knowledge.

Date and Place:

Signature of the applicant