NEBRASKA DEPARTMENT OF ECONOMIC DEVELOPMENT
APPLICATION FOR SBIR/STTR PHASE 0
Part I: Business Information
Business Name:
Address 1:
Address 2:
City:
State:
Business Contact:
Title:
Phone:
Fax:
NE
Zip:
Email:
Federal Tax ID Number:
DUNS Number:
Business Website:
Business organizational structure:
NAIC – North American Industrial Code(s) applicable to main business operations:
Industry:
Describe your business’s background and history:
Describe the main products/processes/services your firm produces:
Describe your previous SBIR/STTR experience, including both successful and failed proposals:
Nebraska Department of Economic Development
SBIR/STTR Phase 0 Application
January 2016
Page 1
Part 2: Federal SBIR/STTR Phase 1 Solicitation Information
SBIR/STTR Agency
Solicitation:
Phase 1 Topic Number:
Phase 1 Solicitation Topic Title:
Solicitation Closing Date:
(Applications must be submitted to DED no later than 30 days before the solicitation closing date.)
Will the business conduct all Phase 1 activities described in the federal SBIR/STTR proposal in Nebraska?
YES
NO
If No, what percent of activities will be conducted in Nebraska?
%
State the overall objective of the Phase 1 proposed research:
Identify and specify the significance of the technical problem or opportunity that will be addressed in
Phase 1:
What is innovative in your concept/proposed approach?
Summarize your awareness about related R&D and the intellectual property currently published on this
subject:
Describe your plans to organize the project team, lab facilities, equipment, and the project budget:
What are the expected results at the end of Phase 1?
What are your Phase 1 objectives to further develop your technology in Phase 2?
Nebraska Department of Economic Development
SBIR/STTR Phase 0 Application
January 2016
Page 2
Describe the timing and duration of Phase 1 work:
What is the end product for commercialization and how will you commercialize the technology?
Who are your customers?
Describe the major milestones or expected outcomes for the development of your Phase 1 proposal:
Project Budget: (Maximum award from Nebraska SBIR/STTR Phase 0 program is $5,000)
Phase 0 Direct Costs
Salaries of individuals related to proposal
Consultant fees
Grant writer
Proposal preparation
Technical Review
Materials and/or supplies
Project related literature
(Other)
(Other)
(Other)
(Other)
TOTAL
Dollar Amount
$
$
$
$
$
$
$
$
$
$
$
$
(Ineligible costs include travel, equipment over $300, facility improvements and legal fees for patents)
If funds are awarded, costs must be documented to receive reimbursement.
CERTIFYING OFFICIAL
To the best of my knowledge and belief, data and information in this application are true and correct. The applicant will
comply with all requirements governing the use of funds.
Signature in ink
Name and Title
Date Signed
DED PROGRAM CONTACT PERSON
For additional information or clarifications of this program, please direct your inquiries to:
Nisha Avey, Business Innovation Consultant
Nebraska Department of Economic
Development
th
301 Centennial Mall South, 4 Floor
P.O. Box 94666
Lincoln, NE 68509-4666
Telephone: (402) 471-1466 or (800) 426-6505
Fax: (402) 471-3778
Email: nisha.avey@nebraska.gov
Website: http:www.neded.org
Nebraska Department of Economic Development
SBIR/STTR Phase 0 Application
January 2016
Page 3