CONFIDENTIAL
The Furnace
A Foundry for Digital Entrepreneurs
(SoC Incubation Centre)
Application Form
Notes to Applicants
1. Please complete all sections of the form (indicate “Nil” or “NA” where appropriate) and
submit it in a sealed envelope to:
The Furnace
Innovation & Entrepreneurship
School of Computing
National University of Singapore
Computing 1
13 Computing Drive
Singapore 117417
2. Please mark “PRIVATE & CONFIDENTIAL” and “THE FURNACE APPLICATION” on the top
left-hand corner of the envelope.
3. This application form must be accompanied by a business plan and a write-up of
technologies.
4. To assist us in evaluating your application, please furnish as concisely as possible the
information requested using the format provided. Please contact us if you have difficulty
in your submission or if you need other information.
5. Please attach any articles, publication or any other relevant information that will help us
in the evaluation of your application.
6. Please insert additional sheets if necessary.
7. Please read the terms found at http://www.comp.nus.edu.sg/entrepreneurship/
8. All information provided will be held in the strictest confidence.
SOCF-APP 02/2014
Page 1 of 4
CONFIDENTIAL
PART I - PARTICULARS OF APPLICANT
Name:
(Underline Last Name)
NRIC No.:
NUS Staff No.:
Fin No.:
NUS Student No.:
Status:
Academic Staff
Graduate Student
Undergraduate
Alumni
Others
(Circle your option)
Faculty & Department:
Degree Programme & Year of Graduation:
Residential Address:
S(
Telephone No.(Residential):
)
Mobile No.:
Email Address:
PART II - PARTICULARS OF ENTITY
Company’s Name:
Website:
Email Address:
Present location, (if it is already formed):
1. Entity type (formed or would be formed)
Limited company
Partnership
Sole proprietorship
2. The entity is a/an
a.
Independent start-up from NUS
If yes for (2a), please complete the following:
Department/Faculty
b.
Spin-off from a research grant
If yes for (2b), please complete the following:
Research Project Title
WBS Number
Funding Agency
Name of Principal Investigator
Department/Faculty
3. Has the entity been registered under Accounting and Corporate Regulatory Authority
(ACRA)?
(Circle your option)
Yes
No
If yes, please attach a copy of BizFile.
SOCF-APP 02/2014
Page 2 of 4
CONFIDENTIAL
4. Please attach individual Curriculum Vitae (max. of two pages) of Key Personnel
(Partners/Directors/Shareholders/Key Employees). Please also include the Key
Personnel’s designation and work commitment (full-time or part-time) in the Curriculum
Vitae.
Total number of full-time staff
Total number of part-time staff
5. Projected Number of Staff (all-inclusive: Tech/Business/Admin):
Projection
After 6 months
After 12 months
After 18 months
Full-Time Staff
Part-Time Staff
6. Please attach a business proposal (max. of 10 pages) with the following points:
You may not need to follow the points in sequence.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
Current business model
Description of technology/system/product, business development and customers
Type of technology and development status
Patent or software/system license
Marketing strategy
List the organizations in similar area of your technology/system/product
Possible collaborator or industrial partner
Deliverables over next 6 months
3 year goals
Projection of quantum of investment
Revenue received through sales, grants, awards, etc.
Organizational structure
7. Have you turned to other sources for assistance to incubate your company?
You may choose more than one if appropriate.
No
Approached another incubator
Approached high-risk venture capital funds
Approached other sources
If yes to any of the above options for question 7, please specify:
SOCF-APP 02/2014
Page 3 of 4
CONFIDENTIAL
PART III - DECLARATION
I, hereby declare that to the best of my knowledge, all statements made and information given
in this form are true and correct.
By filing up this form, I hereby agree and consent that the personal data provided in this form and
attachment may be collected, used, processed and disclosed by NUS for Innovation &
Entrepreneurship activities related in accordance with the Personal Data Protection Act 2012 and
all subsidiary legislation related thereto. I understand that NUS may disclose the personal data to
third parties (which may be in or outside of Singapore) where necessary for the activities related.
I declare and warrant that for any personal data of the contract disclosed by me in this form and
attachment, I have, prior to disclosing such personal data to NUS, obtained the appropriate
consent from the individual whose personal data is being disclosed, to permit NUS to collect,
use and disclose such personal data for the activities related.
Name:
SOCF-APP 02/2014
Signature:
Date:
Page 4 of 4