CzechAccelerator 2011-2014 project
Application for participation in the CzechAccelerator 2011-2014 project
of the Consulting Programme
Supplemental Call to the Call VI
Please select the name of your project:
1
Basic information about the applicant
1.1
Information about the applicant
Name of company
Legal form
Identification number
Tax identification number
Address of the company’s registered office
Date of establishment
Total number of employees
Total number of external partners
Turnover for the last 12 months
1.1.1
Within the CzechAccelerator 2011-2014 project implemented within OPEI, the
applicant may not have its registered office in Prague, with the exception of such
an applicant whose activity is demonstrably connected with the development
and production of a product and services realised in on operations facility
outside of the Prague region.
Address of the place of realization in the
Czech Republic
The applicant shall provide:
1.1.2
Economic data for the past three accounting periods (in CZK ’000). If the
company has been in existence for a period of less than three years, data for all
concluded accounting periods shall be provided. In the case of a newly
established company, the known data available to date shall be provided.
Date of the start and end of the
accounting period (year in the case
of the current accounting period)
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CzechAccelerator 2011-2014 project
Total assets
Total revenues/turnover
Economic result (profit before tax)
Number of internal employees
Number of external workers
1.1.3
Accounting period
Please fulfill the following table:
Start date of the accounting period Last date of the accounting period
Accounting period
1.1.4
I hereby declare that my firm fulfils the definition of a small or medium-sized
enterprise set forth in Annex I of Commission Regulation (EC) No. 800/2008:
Click to select the option:
1.1.5
Company owners1
Name and surname, title
Mobile telephone
E-mail
Name and surname, title
Mobile telephone
E-mail
Name and surname, title
Mobile telephone
E-mail
Name and surname, title
Mobile telephone
E-mail
1
List all owners of the company, including investors or inactive co-owners. Copy the table as needing,
though not outside the context of item 1.3, or use a separate sheet.
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CzechAccelerator 2011-2014 project
1.2
Contact information
1.2.1
Contact person for the CzechAccelerator 2011 – 2014 project
Name and surname, title
Position
Fixed-line telephone
Mobile telephone
E-mail
1.2.2
Key personnel involved in product development and distribution2
Name and surname, title
Position
Mobile telephone
E-mail
Name and surname, title
Position
Mobile telephone
E-mail
Name and surname, title
Position
Mobile telephone
E-mail
Name and surname, title
Position
Mobile telephone
E-mail
Name and surname, title
Position
Mobile telephone
E-mail
2
Please list all key personnel of the company (management, external consultants, mentors, etc.).
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CzechAccelerator 2011-2014 project
1.3
Internet address
1.3.1
URL of the company (or products)
1.3.2
Does your company have a website in English or in the language common in the
destination for which you are registering? If so, please provide the URL. If not,
please state whether and when a foreign-language website will be launched.
1.4
Basic information about the company’s business
1.4.1
Briefly and simply define the company’s business and the opportunity on the
market which the company is endeavouring to exploit (max. one-half A4 page):
1.4.2
Anticipated development of the following indicators (amounts in CZK ’000; data
for the company)
Year
Total assets
Total revenues/turnover
Economic result (profit
before tax)
Number of internal
employees
Number of external workers
1.5
2013
2014
2015
Product
1.5.1
Please specify the sector for which your product is intended (the technological
focus of the destination must be in accordance with the technological focus of
the product)
Click to select the option:
1.5.2
Please provide the name of your product
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CzechAccelerator 2011-2014 project
1.5.3
Description of the product
a) Briefly describe the basic characteristics of your product (max. 10 lines)
Brief description of the product?
What problem will the product resolve?
What purpose (user) will the product serve?
What is the motive that led to the product’s
development?
b) Briefly describe the way in which your product or service is exceptional, interesting, unique
(maximum five lines).
c) Is the product already completed and prepared to be offered to customers?
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d) If the product is in the beta-version, prototype or trial-version phase, describe your plans
for finishing the product (time horizon, roadmap for further development, the current phase
of the product’s development, resources required for bringing the product to market,
factors on which bringing the product to market depends, etc.).
e) How and when will the product be realised in practice – introduced to the market?
f) What percentage of the offered product do you own? Please state the share of ownership
of the product in percent (at least 51% ownership of the product is a condition of
participation)
g) Brief description of the product’s technological solution (technologies used, processes
used in development, other information explaining the product’s development (max. one
A4 page).
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CzechAccelerator 2011-2014 project
h) Who is the end customer for your product and how will you introduce and market the
product? How big will the market be?
i)
What is the business model for the product (i.e. price, sales and distribution model)?
j)
Please list the main competitors and your company’s competitive advantages.
k) Are there alternatives to your product?
l)
Please describe your company’s key partnership.
m) Provide a SWOT analysis of the product (i.e. identify the strengths and weaknesses of
your product and opportunities and threats in relation to your product).
1.6
Financial, commercial and legal information
Please provide the financial, commercial and legal information about the product
according to the required outline (max. one A4 page)
Required outline:
a) Amount of investment needed for successfully introducing the planned products to the
market.
b) Within what period of time do you expect the product to become profitable following its
introduction to the market?
c) Estimated annual costs and revenues connected with the product in 2014.
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CzechAccelerator 2011-2014 project
d) Are you currently seeking a financial investor?
e) The company’s previous financing (please specify whether the company was financed
from its own resources and/or bank loans, by a private investor, etc.)
f) Intellectual property
Please list all patents and other intellectual property of the company.
2
Stay in the destination
2.1
Choose destination and period3
Click to select an option
2.2
Time schedule of the residency:
The applicant shall bear in mind that, in the case of approval of the applicant’s project, the
residency in the destination shall be realised during the following time period:
Day of entry into office spaces in the destination
Date of termination of the residency (handover
of the office spaces) in the destination
2.3
28. 4. 2014
27. 6. 2014
Results, financial expectations
a) Will you actively seek a financial investor in the destination?
Click to select an option:
b) If so, how much funding will you request and how large a stake in the company are you
willing to offer to the investor?
c) What specifically do you expect from the stay in the accelerator?
3
Select only one option.
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CzechAccelerator 2011-2014 project
2.4
Other
a) How many employees or associates do you intend to dispatch to the technology
accelerator? (It is possible to send a maximum of two employees).4
1
2
Name and surname, title
Position
Name and surname, title
Position
b) Following any possible success (i.e. finding an investor or other strategic partner), do you
intend to return to the Czech Republic and work on the development of your company and
product in the Czech Republic? Are you willing to establish a branch in the country where
your selected destination is located? Please briefly describe your plans (max. one-quarter
A4 page):
c) Please describe the individual initial steps to be taken during the stay in the accelerator
(max. one-quarter A4 page):
d) The supported activities within the CzechAccelerator 2011-2014 project include, in
particular, provision of consulting services to start-up and innovative SMEs with the
objective of overcoming a deficiency of experience and financial resources for effective
penetration of new technology markets. Taking into consideration the rules of the project,
what type of consulting services do you intend to use in the destination and in what areas?
Do you plan to use the services of mentors and coaches in the destination? If so, in what
areas should a mentor assist you?
e) Part of the services provided within the project comprises participation in marketing
events. Do you plan to attend any marketing events during your stay in the destination? If
so, to what degree (approx. number of events per month)? Do you know of any particular
event that you would like to attend in the destination? If so, please state which one.
4
Select only one option
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CzechAccelerator 2011-2014 project
f)
Within the CzechAccelerator 2011-2014 project, are you planning to use the supported
services and to apply for a patent, industrial design, utility model or registered trademark
for you product?
g) Do you have experience with financing by an investor or cooperation with a foreign
partner? If so, please specify the type of cooperation and the cooperating partner.
h) Do you give CzechInvest your consent to publish basic information about your company or
product and to use such information in media presentations?5
Click to select an option:
i)
How did you find out the CzechAccelerator 2011 – 2014 project?
j)
Here you can provide any additional information which you consider important for us to
know.
5
CzechInvest undertakes that for media presentations it will use only basic information about the product
and will not publish any sensitive information. Every press release and other information provided to
journalists will be consulted with the owner of the product.
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CzechAccelerator 2011-2014 project
3
Declaration
The applicant for participation in the CzechAccelerator 2011-2014 project hereby declares that as
of the date of submitting this registration form it fulfils the following criteria and conditions:
1. it is the 100% or majority holder of the proprietary rights of the offered product.
2. it is completely blameless in financial arrears and does not have any outstanding tax
liabilities or other liabilities toward the state or private entities. At the same time, the
submitter of the project declares that it is not registered as a debtor and that its assets are
not the subject of an involuntary auction or execution, and that it is not in bankruptcy,
liquidation or insolvency.
3. that it is able and willing to expend sufficient financial resources for ensuring the stay of its
dispatched employees in the selected destination for the necessary period of time for the
purpose of achieving the objectives of the project.
4. it has its own management and product-development teams which operate fully or at least
51% of the time in the Czech Republic. Time is understood to be the period worked on the
basis of a contractual relationship within the given company (e.g. employment relationship
– employment contract or agreement – agreement on performance of work, agreement on
work activity, or employment contract with an employment agency); i.e. at least 51% of the
time worked in the given company must be realised in the Czech Republic.
5. its employees dispatched to the technology accelerator can reside without special
restrictions in the country of the selected destination (for example, such employees have
not been previously barred from entering the given country and are not subject to other
administrative barriers).
6. in the event of success in the selection procedure, the participant is fully committed and
prepared to depart to the chosen destination on the designated date6.
7. shall bear in mind that in order to receive aid from CzechInvest, it is necessary to conclude
a Contract on Project Participation.
8. the applicant is familiar with the text and conditions of the CzechAccelerator 2011-2014
project, is aware of all rights and obligations and the legal consequences ensuing from a
breach of the obligations that are connected with the provision of aid, and is not aware of
anything that could hinder the applicant in fulfilling any of the stipulated conditions.
9. all information submitted by the applicant is accurate and factual. The applicant is also
aware of the possible legal ramifications in the event that it is determined that aid was
provided on the basis of inaccurate data submitted by the applicant.
10. by submitting the registration form, the applicant declares that it unreservedly accepts all
conditions stipulated by CzechInvest in the Call set forth on the website at
www.czechaccelerator.cz.
6
The time periods of participation set forth in the registration form are not binding for CzechInvest.
CzechInvest reserves the right to change, upon agreement with the project participant, the date of the start
and termination of the residency in the given destination or to reduce the total time period of the residency.
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CzechAccelerator 2011-2014 project
11. the applicant shall provide to CzechInvest maximum cooperation in the course of the
evaluation of the application and, in particular, shall provide, upon CzechInvest’s request,
additional information that is necessary for assessment of the application. The applicant is
aware that in the event of failure to provide such requested additional information,
CzechInvest shall reject the application
The applicant hereby declares that as of the date of submitting this registration form it fulfils the
following criteria and conditions:
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The applicant is authorised to conduct business in the Czech Republic corresponding to
the supported economic activity for the realisation of which the project is to be
implemented.
The applicant is registered as an income-tax payer with the Tax Office pursuant to section
125(1) of Act No. 280/2009 Coll., the Tax Code, as amended.
The applicant does not have any outstanding liabilities toward selected institutions. (Tax
Office, the Czech Social Security Administration, health-insurance companies, Land Fund,
Ministry of Finance as the legal successor of the National Property Fund, State
Environmental Fund, State Housing Development Fund, Customs Administration of the
Czech Republic, State Cultural Fund, State Fund of the Czech Republic for Support and
Development of Czech Cinematography, State Agricultural Intervention Fund, regions,
municipalities and associations of municipalities) or toward providers of aid for projects cofinanced from the European Union budget. Deferment of payment of outstanding liabilities
or an agreement on the payment of outstanding liabilities shall be considered as settled
liabilities.
According to the applicant’s affidavit, the applicant may not have any outstanding liabilities
towards its employees regarding wage claims.
If the applicant is a natural person, such natural person declares that a ban on an activity
concerning the conduct of the given activity has not been imposed upon him/her by a
court or administrative body.
The participant’s project may not be within the sectors of primary production of agricultural
products, fishing and aquaculture (CZ-NACE A01 and A03) or other sectors excluded
pursuant to Commission Regulation (EC) No. 1998/2006.
The applicant shall fulfil the definition of a small or medium-sized enterprise set
forth in Annex I of Commission Regulation (EC) No. 800/2008.
The result of involvement in CzechAccelerator will be manifested in an activity
demonstrably connected with the development or production of a product or
service realised in an operating facility located in the Czech Republic, but outside of
Prague.
The applicant does not have the legal form of a joint-stock company with documentary
bearer shares pursuant to Act No. 171/2012 Coll., on Budgetary Rules and on the
Amendment of Certain Related Acts.
As of the date of submission of the application, bankruptcy has not been declared against
the applicant’s assets, a forced settlement has not been imposed, and a proposal for
declaration of bankruptcy has not be rejected due to lack of assets, nor has an order of
execution against the applicant, nor is the applicant in bankruptcy or liquidation.
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As of the date of submission of the application, no ruling on bankruptcy has been issued
against the applicant pursuant to the provisions of Section 136 of Act No. 182/2006 Coll.,
on Insolvency.
As of the date of submission of the application, the applicant is not registered as a debtor
in the database of debtors.
The applicant does not have any outstanding liabilities in terms of wage claims toward its
employees.
A court has not issued a ruling on execution of a decision against the applicant’s assets or
ordered the execution of the applicant’s assets.
The applicant is not an enterprise in difficulties (pursuant to Commission Regulation (EC)
No. 800/2008).
The applicant is not an enterprise that, as of the date of submission of the application, is a
recipient of aid pursuant to European Community Guidelines No. 2004/C244/02.
The applicant does not have an outstanding liability arising on the basis of an order to
return financial resources issued following a prior ruling of the Commission declaring that
aid is contrary to law and incompatible with the common market.
The applicant is not a recipient of aid for young, innovative enterprises pursuant to Article
35 of Commission Regulation (EC) No. 800/2008, provided less than three years prior to
the date of submission of the aid application.
CzechInvest reserves the right to verify the accuracy and veracity of all of the above-mentioned
information.
The applicant agrees that:
a) CzechInvest and the Ministry of Industry and Trade shall process, by all necessary and
suitable means, all data set forth in the project-participation application form (including all
personal data) and other documents provided by the project participant in connection with
the project for the purpose of assessment and administration of the application and
evaluation thereof, project inspection and monitoring, assurance of the public’s awareness
and publicity of the project and for the purpose of performance and other rights and
obligations of CzechInvest and the Ministry of Industry and Trade connected with the
provision of aid and assessment of the project and the payment application.
b) CzechInvest shall share data and provide materials provided by the applicant with third
parties that are participating in the implementation of the CzechAccelerator 2011-2014
project for the purpose of assessment and administration of the application and evaluation
thereof, processing, decision-making on the possible provision of aid, assessment,
inspection and monitoring of the project, assurance of the public’s awareness and publicity
of the project and for the purpose of performance and other rights and obligations of
CzechInvest and the Ministry of Industry and Trade connected with the provision of aid
and assessment of the project and the payment application, possibly to other parties
whose awareness is necessary for the proper implementation and monitoring of the
project.
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4
Notice on provision of de minimis aid
In the given three-year fiscal period, the total amount of de minimis aid provided to one enterprise
may not exceed the amount of EUR 200,000. Aid fulfilling the conditions set forth in Article 2(2-5)
of the Regulation is compatible with the EU common market and is not subject to the notification
obligation pursuant to Article 88(3) of the EC Treaty. For conversion of the amount of aid from
OPEI pursuant to the de minimis rule, the exchange rate announced by the European
Commission in the Official Journal of the European Union on the date of signing the Contract on
Cooperation, which governs the conditions of aid provision within the Operational Programme
Enterprise and Innovation, in accordance with Commission Regulation (EC) No. 1998/2006, will
be used.
The applicant declares that it is familiar with the character of de minimis aid pursuant to
Commission Regulation (ES) No. 1998/2006 and further declares hereby that in the course of the
last three accounting periods7, the applicant:
a) has not received any de minimis aid.
b) has received de minimis aid, though the sum of received aid and aid
declared within OPEI does not exceed the permitted limit of EUR 200,000.
CzechInvest reserves the right to verify the accuracy and veracity of all of the above-mentioned
information.
In
, date
………………………………………
Applicant’s signature
[Persons authorised for signing according to the Commercial Register and statutes or stamp, as
the case may be]
7
Select only one option
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CzechAccelerator 2011-2014 project
Annexes
Appellation of the Annex
1.
2.
3.
4.
5.
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