ENTRY FORM Key Contact Information: First name: Last name: Email: Phone: Company Information: Company name: Year founded: Company website: FTEs: Industry: Company registration no. Company Description: Summary: (Describe your business in a few sentences – 50 words) Traction: (Describe the stage of the business including any product development, customers / sales and partnerships – 200 words) Market: (Describe the global market trends, size, customers, players and competitors – 200 words) Product / Technology: (Describe your unique product and/or technology – 200 words) Team: (Provide info on the key individuals of the team and board if applicable, including LinkedIn profile if available – 300 words) Funding History: (Outline any previous funding sources) How will winning the Samsung Springboard help your business? (To see the value up for grabs see www.samsungspringboard.co.nz – 400 words) Send your completed form to: c.geissler@theicehouse.co.nz Samsung Springboard Competition - Terms & Conditions: By submitting an application to enter the Samsung Springboard competition (“Samsung Springboard Competition”), you agree to the following terms and conditions (“Terms & Conditions”): 1. This Samsung Springboard Competition is only open to entries from New Zealand residents who are at least 18 years of age, or New Zealand companies having 50% or more of their shares held by New Zealand residents ("Applicants"). Applications must be received via c.geissler@theicehouse.co.nz no later than 5:00pm on 20 September 2015. 2. By considering or accepting applications to enter the Samsung Springboard Competition, neither The Icehouse Limited (the “Promoter”) , Samsung Electronics New Zealand Limited (“Samsung”), nor any of their associates, imply endorsement of the Applicant, the Applicant’s business, or the Applicant’s products or services. 3. Each Applicant hereby grants to the Promoter and Samsung a royalty free, perpetual, worldwide license to use the information contained in their application for all purposes necessary to manage and promote the Samsung Springboard Competition including the Promoter, Samsung and their associates, partner companies, and their respective businesses, including disclosing application entries to third parties. With respect to any publicity surrounding the Samsung Springboard Competition, the Promoter and Samsung will take care to ensure no confidential information of the Applicant is disclosed without permission of the Applicant. The onus is on the Applicant to specifically identify and label confidential information in its application. 4. Each Applicant hereby agrees that it will not at any time, without the Promoter’s prior written consent, disclose or reveal publicly or to any third party any information during the Samsung Springboard Competition, including any terms of funding or assistance offered by the Promoter, Samsung or any of their associates to Samsung Springboard Competition Applicants. All Applicants will be required to sign a confidentiality agreement in order to participate in the Samsung Springboard Competition. 5. All Applicant expenses incurred in connection with participation in the Samsung Springboard Competition and in acceptance of prizes, unless specifically stated in these Terms & Conditions, are the sole responsibility of the Applicant. 6. Each Applicant hereby agrees to allow its name and likenesses to be used for promotional purposes by the Promoter and Samsung, and for its participation in the Samsung Springboard Competition to be recorded without compensation, if required by the Promoter or Samsung, for use by the Promoter or Samsung for advertising and publicity purposes including in relation to the Samsung Springboard Competition. 7. Each Applicant who is the recipient of funding from the Promoter as a result of their participation in the Samsung Springboard Competition hereby agrees to take part in publicity accompanying or resulting from the Samsung Springboard Competition. 8. Each Applicant hereby agrees that it will make no public announcement regarding the Samsung Springboard Competition without the consent of the Promoters. Awardees will be entitled to publicise their status once the Promoters have announced the Samsung Springboard Competition results publicly. 9. The list of Applicants and awardees may be published on the Samsung Springboard website. 10. Entry into the Samsung Springboard Competition does not grant rights to use the Springboard name, logo or any images from or relating to the Samsung Springboard Competition events without the express written approval of the Promoter. All rights are reserved. 11. The Promoter and/or Samsung reserves the right to cancel, amend or withdraw the Samsung Springboard Competition or these Terms & Conditions at any time and will endeavour to give advance notice of any such change or withdrawal. However, in some cases, advanced notice may not be possible. 12. Under no circumstances will the Promoter or Samsung, or their associates, subsidiaries and affiliated companies be liable for any losses, damages, costs, or expenses arising from or in any way connected with the Samsung Springboard Competition (including any discontinuance of the Samsung Springboard Competition) or relating to the Applicant's business, product or services. 13. Each Applicant hereby acknowledges that in entering the Samsung Springboard Competition, it has not relied on any representation, warranty or undertaking. Nothing shall exclude the Promoter's liability for death or personal injury as a result of its negligence or in relation to fraudulent misrepresentation. 14. The Samsung Springboard Competition and these Terms & Conditions will be governed by New Zealand law and any dispute will be determined by the exclusive jurisdiction of the New Zealand courts. 15. The Promoter reserves the right to exclude any entry application from the Samsung Springboard Competition at its sole discretion. 16. Entry applications must be in respect of a business that is able to provide a set of audited accounts or an independently verified version of financial statements. 17. Only one entry application per business (including per group of related companies) will be considered. Applicants must provide details of their principal place of business. In the event that more than one entry application is submitted in respect of any business, only the first application will be considered. 18. Applicants agree to make further information available in accordance with the Promoter's requests and due diligence requirements. 19. By entering the Samsung Springboard Competition, each Applicant warrants that all information that it submits is true, current, and complete. All Applicants warrant that the information submitted by them will not infringe the intellectual property, privacy or any other rights of any third party, and will not contain anything that is libellous, defamatory, obscene, indecent, harassing or threatening. 20. The Promoter reserves the right to disqualify any Applicant if the Promoter has grounds to believe the Applicant has breached any of these Terms & Conditions or provided false or misleading information in its entry application. 21. In the event that any Applicant is disqualified from the Samsung Springboard Competition, the Promoter may withdraw any award, prize, or funding from that Applicant’s business and publicise that withdrawal. The Promoter, in its sole discretion, may decide whether a replacement Applicant should be selected. In this event, any further Applicant will be selected on the same criteria as the original Applicant and will be subject to these Terms & Conditions.