State of New Jersey
New Jersey Commission on Science and Technology
New Jersey Technology Fellowship
Second Year Application
Fellowship Applicant Name:
E-mail:
Company Name:
Company Address:
Fellowship Phone Number:
Company Contact Phone Number:
Company Contact Name:
Company Contact E-mail:
Timetable for required submissions:
Fourth Round Funding
October 1, 2009 – 3:00pm
November 2009
Public Project Description
Provide a separate half page brief description of both the company and the proposed project. PLEASE
USE NON-TECHNICAL, LAY LANGUAGE. Do not include proprietary or confidential information.
If the application is funded, this description will be made public.
Performance Report Guidelines
The Report should be concise, yet sufficiently detailed to provide a comprehensive overview of
the activities and achievements of the program for the grant period, relative to the Annual Work
Plan. Variances from the Annual Work Plan should be identified and explained.
The Report should be provided in the following format:
I.
Program Objectives, Milestones, Outcomes, and Deliverables
A.
Describe your achievements against Mid-Year and Year-End Plan objectives,
milestones, outcomes and deliverables during the grant period.
B.
Describe your achievements in the following areas:
1. Science and Technology
2. Impact on the Company: (please describe the impact that the fellowship has had on the
company in the following areas)
a. pathways to commercialization
b. benefits in employment
c. new and expanded businesses
d. infrastructure development
3. What are your career plans beyond year 2 of the fellowship?
4. What steps were taken to mentor your experience during the first year of the fellowship?
5. University Relationship
a. Demonstrate the degree to which the fellowship program established a
relationship between the company and candidate’s degree granting university, use
specific examples if possible
b. Explain the degree to which combined candidate and company fellowship effects
transfer of technology and technical experience from university to company.
6. Non-Commission Resources - What resources has the company obtained since beginning
the fellowship? (i.e. venture funding, other private investments, other public funding)
II.
Company Numerical Achievement Data
Provide the following numerical achievement data since the start of the fellowship:
A.
B.
C.
D.
E.
F.
G.
Company Revenue
Number of invention disclosures filed
Number of patent applications filed
Number of patents received
Number of intellectual property licenses or equivalent agreements executed
Number of employees
Amount of third party financing
Renewal Statement
Please include a statement from both the Technology Fellow and the Company. Each statement
should be no longer than one page. In these statements please explain why you are interested in
continuing with a second-year of the fellowship and what you are hoping to gain from a
continued experience with this program.
Work Plan
Please include a brief work plan including timeline and milestones agreed upon by both the
fellow and company for Year 2 of the fellowship. This should include a discussion and
justification on how the expense grant is to be used.
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Eligibility and Disclosures
Have any of the persons or entities listed above:
been, within the last five years, a party in litigation?
Yes
No
been, or is now, charged with, convicted of, under indictment, on parole, on probation or a plaintiff in,
any criminal or civil offence other than a minor motor vehicle violation?
Yes
No
been, or is now, subject to, or has pending, any disciplinary action by any administrative, governmental or
regulatory body?
Yes
No
been, or is now, subject to any order resulting from any criminal, civil or administrative proceedings
brought against such persons or parties by any administrative, government or regulatory body?
Yes
No
been, or is now, denied any license by any administrative, government or regulatory agency on the
grounds of moral turpitude?
Yes
No
been, or is now, informed of any current or on-going investigation with respect to possible violation by
such persons or parties of state or federal securities, anti-trust or criminal laws?
Yes
No
been, or is now, denied a business or professional-related license or had it suspended or revoked by any
administrative, government or regulatory agency?
Yes
No
been, or is now, disbarred, suspended or disqualified from contracting with any federal, state or municipal
agency?
Yes
No
been, or is now, in receivership or adjudicated bankrupt?
Yes
No
been, or is now, in default on a personal or business loan?
Yes
No
is now involved in any pending lawsuits?
Yes
No
If the answer is “yes” to any of the questions above, furnish details on a separate page under the heading
“ELIGIBILITY AND DISCLOSURES”. Any information you wish to submit that may expedite this
investigation should be set forth as an attachment.
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Company Affidavit
I, THE UNDERSIGNED, BEING DULY SWORN UPON MY OATH SAY:
1. I affirm, represent and warrant that the information contained in this application and all
attachments submitted herewith is true and complete to the best of my knowledge and that the
grant applied for herein is not for personal, family or household purposes.
2. I understand that if such information is willfully false or eligibility for the Technology
Fellowship Program is falsely certified I am subject to criminal prosecution under N.J.S.A.
2C:28-1, 2C:28-2 and 2C:28-3, as applicable and civil action by the New Jersey Commission on
Science and Technology (“Commission”) which may at its option terminate its grant.
3. I authorize the New Jersey Department of Law and Public Safety to verify any answer(s) and
information contained herein through a search of its records or records to which it has access and
to release the results of said research to the Commission.
4. I authorize the Commission to obtain such information including, but not limited to, a credit
bureau check as it may require, covering the applicant and/or its principals.
5. I understand that the Commission will retain this application and all associated documents,
whether or not this application is approved.
_______________________________________________
Signature of Company Official
________________________________________________
Name and Title of Company Official (Print or Type)
_________________
Date
Sworn and Subscribed before me this ___
day of ___ 20__
________________________
NOTARY PUBLIC
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Application Checklist
Before submitting the application, applicants must complete this checklist to ensure that they
have included all of the necessary information.
Application forms with signatures
Work plan (no more than 10 pages)
Gantt chart showing the proposed milestones and timeline
Public project description (half page project and company summary)
Eligibility and disclosures statement
Application affidavit with notary
Payroll Schedule
Application Submission
Send the original signed copy of the documents and the complete Grant Proposal on a CD
in PDF format to the Commission at the address below.
Overnight:
New Jersey Commission on Science and Technology
New Jersey Technology Fellowship Program
10 South Montgomery Street
Trenton, NJ 08625
U.S. Postal Service:
New Jersey Commission on Science and Technology
New Jersey Technology Fellowship Program
P.O. Box 832
Trenton, NJ 08625
For Additional Information
Please contact the New Jersey Commission on Science and Technology at (609) 984-1671 or
njcst@scitech.state.nj.us.
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