Application form
I, ___________________ born in ___________________ (province _____) on __________
Tax code ___________________
_________)
____
resident
Street
____________________________
______________________________
in
_____________
____
Code
_______
Postal
Email
____________________
___________________________________________
(province
City
Telephone
As owner / legal representative (specify role) _________________________
Of the company ______________________________ active since ____________________
(otherwise specify that the company is still to be formed)
Insert Fax number _______________ or PEC (registered email) __________________ to
which notification of the assessment will be sent
In compliance with articles 46 and 47 of Presidential Decree 445/2000, and aware of the
punishment in the case of false or mendacious declarations,
HEREBY DECLARE


That I possess all the requisites required for participation in this tender process,
particularly in relation to article 3
The following information on the applicant company:
Legal status: __________________
Sector: _________________________
Capital stock: __________________ (Value in 000/€)
Company composition: _______________________________________________________
___________________________________________________________________________
Tax
Code:
______________________________
_____________________________
VAT
Code:
Activity (specify_____________________________________________________
Legal address ____________________________ Street: _____________________________
n°: ____
Operative
address:
__________________
_______________________ n°: ____
Postal
Code:
If working company
If data is available:
Profit from the sales and services _______________________
(from latest approved profit and loss statement)
Value in 000/€
ASK
1
_________
Street:
To access the incubator/accelerator services for the establishment of my business using (tick
the box corresponding to your choice)
□ INCUBATOR office use
Fill out Appendix A
□ ACCELERATOR laboratory/office use
Fill out Appendix B
□ virtual space
2
APPENDIX A
Specify:
□
Spaces in via Taramelli
1. Size of the required spaces
Space
Fee 1st year
Fee 2nd year
Fee 3rd year
□
Size S (about 25 m2)
€3900.00
€4100.00
€4300.00
□
Size XS (about 18
m2)
€2800.00
€3000.00
€3200.00
2. Office furniture
□
□
□
1
2
desk
□
chairs
□
2
4
desks
chairs
Spaces in Piazza Petrarca
It will not be possible to select these spaces until July 2015; the information concerning these
spaces will be updated by that time.
PLEASE NOTE: the information supplied will be assessed compatibly with the availability of space
and furniture
Place and Date
Stamp and Signature
……………………………………
Information in compliance with article 13 of Legislative Decree n° 196/2003 "Code on protection of
personal details"
In compliance with article 13 of Legislative Decree n° 196/2003 containing instructions on the protection of personal
details, we would like to inform you that the details you supply will be treated, with or without the help of
computerised information, exclusively for the purposes and activities of the Entity and in particular in relation to the
reference administrative procedure, for which the supply of these details is obligatory and the corresponding treatment
does not require consent from those involved. The details will be made available to third parties within the limits and
by the procedures indicated in current regulations on administrative transparency and the right of access to acts. The
subject who owns the details may exercise, at any time, their rights indicated in article 7 of Legislative Decree n°
196/2003. The owner of the right to treat these details is Parco Tecnico Scientifico Pavia a r.l. represented by
president Antonio Majocchi.
The undersigned - aware that sending the detals is necessary for participation in this tender process and that failure to
communicate them excludes the establishment or continuation of relations with Parco Tecnico Scentifico a r.l. declares that they have received the information contained in article 13 of Legislative Decree 196/2003 containing the
"Code on protecting personal details" concerning the treatment of transmitted personal details, that they are aware of
their rights in compliance with article 7 of the aforementioned regulation and they authorise Parco Tecnico Scientifico
Pavia a r.l. to deal with their details in compliance with current regulations.
Signature ………………………………………
3
APPENDIX B
Specify:
3. Size of the required spaces
□
□
□
Space
Fee 1st year
Fee 2nd year
Fee 3rd year
Size XL (about 40
m2)
Size L (about 35 m2)
€7000
€7300
€7700
€6300.00
€6600
€7000
€5500.00
€5700
€6000
€4700.00
€5000
€5300
Size M (about 30
m2)
Size S (about 25 m2)
□
4. Furniture for the laboratories/offices
□
□
□
Counter for chemical activities, tick C in the furniture list
Counter for biological activities
1 Ventilated cabinet
Number of counters/technical tables:
□
1
side counter 150x75 cm (C )
□
2
side counters 150x75 cm (C )
□
1
central counter 150x150 cm (C )
□
2
central counters 150x150 cm (C )
□
1
Side technical table 150x150 cm
□
2
Side technical tables 150x150 cm
□
1
Side technical table 150x150 cm
□
2
Side technical tables 150x150 cm
5. Select technical gases and their position:
□
□
□
CO2 central counter
CO2 side counter
Nitrogen (to tap)
□
□
Vacuum pump central counter
Vacuum pump side counter
Also indicate:
□
□
___
___
□
shelves
□
1
□
□
closed lockers
___
desk
chairs
170x75 cm
___ filing cabinets
___ cupboards
2 desks 170x75 cm
___ high stools
□
□
PLEASE NOTE: the information supplied will be assessed compatibly with the availability of space
and furniture
Parco Scientifico Life Sciences Pavia has carried out a survey of scientific instruments that may
be supplied to the companies who settle in.
4
We would like the applicants to please indicate whether they would be interested in the
following instruments, indicating from 0 to 5 the importance ascribed to each instrument in
carrying out their business activities. In the "paid service" column, indicate whether you would
be available to pay third parties for the service.
Importance
Description of the instrument
1
(0
5)
Biacore T200 - Macromolecular interaction
measurements
2
FFF Multiflow AF200
3
5
Semi-industrial electrospinning
Olympus Morada G2 Camera for Zeiss EM 900
microscope
Platform for seed quality analysis
6
MALDI TOF/TOF mass spectrometer
4
–
Paid services (YES NO)
We will evaluate the possibility of purchasing the following further instruments in light of
planning choices and available resources.
Importance
Description of the instrument
7
8
9
(1
–
5)
Paid services (YES NO)
Nano Spray Drying System - sprayer for micro and nano
particles
MicroCal iTC200 for measuring bond affinity and
thermodynamic constants
Advanced system for natural and artificial polymer
chromatography (Acquity)
Place and Date
Stamp and Signature
……………………………………
Information in compliance with article 13 of Legislative Decree n° 196/2003 "Code on protection of
personal details"
In compliance with article 13 of Legislative Decree n° 196/2003 containing instructions on the protection of personal
details, we would like to inform you that the details you supply will be treated, with or without the help of
computerised information, exclusively for the purposes and activities of the Entity and in particular in relation to the
reference administrative procedure, for which the supply of these details is obligatory and the corresponding treatment
does not require consent from those involved. The details will be made available to third parties within the limits and
by the procedures indicated in current regulations on administrative transparency and the right of access to acts. The
subject who owns the details may exercise, at any time, their rights indicated in article 7 of Legislative Decree n°
196/2003. The owner of the right to treat these details is Parco Tecnico Scientifico Pavia a r.l. represented by
president Antonio Majocchi.
The undersigned - aware that sending the detals is necessary for participation in this tender process and that failure to
communicate them excludes the establishment or continuation of relations with Parco Tecnico Scentifico a r.l. declares that they have received the information contained in article 13 of Legislative Decree 196/2003 containing the
"Code on protecting personal details" concerning the treatment of transmitted personal details, that they are aware of
their rights in compliance with article 7 of the aforementioned regulation and they authorise Parco Tecnico Scientifico
Pavia a r.l. to deal with their details in compliance with current regulations.
Signature ………………………………………
5
ATTACH:
-
Deed of incorporation and articles of association (if the company has already been
formed);
Business Plan (reference plan, Attachment B in the tender notice)
Photocopy if identity document
If the company is already running (for no more than twelve months before presentation of
the application):
-
A copy of the last approved profit and loss statement, if available;
A certificate of enrolment in the Business Register no older than 3 months and including
the declaration of validity and anti-mafia indications.
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