CzechAccelerator 2011-2014 project
Application for participation in the CzechAccelerator 2011-2012 project
of the Consulting Programme
Call V
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.
Such operations facility must be entered in the Commercial Register or Trade Licensing
Register as at the date of submission of the registration form.
Address of the place of realization in the
Czech Republic
1.1.2
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:
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CzechAccelerator 2011-2014 project
1.1.3
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
1.2
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
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.
2
Please list all key personnel of the company (management, external consultants, mentors, etc.).
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CzechAccelerator 2011-2014 project
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
1.3
Internet address
URL of the company (or products)
1.4
Basic information about the company’s business
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):
1.5
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
1.5.3
Describe the product according to the required outline (max. two A4 pages)
Required outline:
a) Briefly describe the basic characteristics of your product (its interesting aspects and
uniqueness) and the motivation that led to its development
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CzechAccelerator 2011-2014 project
b) Who is the end customer for your product and how will you introduce and market the
product? How big will the market be?
c) Basic description of the product’s development (period of development, roadmap, the
current development phase, and whether there is a trial version, prototype or beta version
of the product?)
d) What is the business model for the product (i.e. price, sales and distribution model)?
e) Please list the main competitors and your company’s competitive advantages.
f)
Are there alternatives to your product?
g) Please describe your company’s key partnership.
1.5.4
Is the product already completed and prepared to be offered to customers?
Click to select an option:
1.5.5
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)
1.5.6
Product technology
Please describe the technology of the product according to the required outline (max one A4
page).
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CzechAccelerator 2011-2014 project
Required toutline3:
a) Brief description of the technological solution of the product (the utilised technologies and
development processes, other information explaining the product’s development)
b) In what way is the product technologically unique and interesting?
c) How and when will the product be realised in practise?
1.5.7
Intellectual property
Please list all patents and other intellectual property of the company.
1.5.8
1.6
SWOT analysis of the product
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
d) Are you currently seeking a financial investor?
3
You can also submit various prepared materials and photo-documentation.
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CzechAccelerator 2011-2014 project
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.)
2
Stay in the destination
2.1
Preferred destination and period4
Click to select an option
2.2
Alternate destination and period (in the case that the preferred destination is fully
occupied)4
Click to select an option
2.3
Specify the time period of the stay in the destination (It is possible to choose one
residency comprising a single stay or a residency divided into two parts; please
complete only part “a” or “b”) 4
a) One stay with duration of 3-6 months. Please specify the time period of the stay (date of
entry and expected date of termination):
Day of entry
Expected data of termination
Select:
Select:
b) Two stays during six months. The total duration of both stays must be at least four
months. Specify the time periods5 :
1st stay
Day of entry
Expected data of
termination
2.4
2nd stay
Select:
Select:
Day of entry
Expected data of
termination
Select:
Select:
Results, financial expectations
Will you actively seek a financial investor in the destination?
4
Select only one option.
5
One stay may not be shorter than one month and there must be an interval of at least one
month between individual stays. The total duration of both stays combined must be at least four
months.
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Click to select an option:
If so, how much funding will you request and how large a stake in the company are you willing to
offer to the investor?
What specifically do you expect from the stay in the accelerator?
2.5
Other
How many employees or associates do you intend to dispatch to the technology accelerator? (It is
possible to send a maximum of two employees).6
1
2
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):
Please describe the individual initial steps to be taken during the stay in the accelerator (max.
one-quarter A4 page):
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. With respect to the rules of the project, what kind of consulting services do
you intend to use in the case of your stay in the destination?
6
Select only one option
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CzechAccelerator 2011-2014 project
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?
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.
Do you give CzechInvest your consent to publish basic information about your company or
product and to use such information in media presentations?7
Click to select an option:
Here you can provide any additional information which you consider important for us to know.
7
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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3
Declaration
The applicant for participation in the CzechAccelerator 2011-2014 project declares that
1. it is the 100% or majority holder of the proprietary rights of the offered product. If this is not
the case, the applicant shall demonstrate, within the shortest possible time and upon
agreement with CzechInvest, the full consent of the other owners of such rights to the use
of the product in the technology accelerator. In the case of non-fulfilment of this condition,
the applicant will be excluded from the selection procedure.
2. it is not 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. if it is successful in the selection process, it is fully determined and prepared to depart to
the selected destination on the date selected by the applicant8.
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.
8
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
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.
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 further declares that 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 may 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 co-financed 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.
An entity cannot be an aid applicant if as of the date of submission of the application:
 pursuant to the Act on Bankruptcy and Settlement, a court has declared bankruptcy
against its assets, permitted a settlement or rejected a proposal for declaration of
bankruptcy to insufficient assets.
 a ruling on its insolvency has been issued pursuant to Section 136 of Act No. 182/2006
Coll., on Insolvency.
 a court has issued a ruling on the order of enforcement of a decision on the given entity’s
assets or has ordered the execution of its assets.
 it is in liquidation.
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such entity is registered as a debtor in the database of debtors.it is an enterprise in
difficulties (Commission Regulation (EC) No. 800/2008).
it has an outstanding liability arising on the basis on an order to return financial resources
issued following a previous ruling of the Commission declaring that aid is contrary to law
and incompatible with the common market.
it is 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.
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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 periods9, 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.
De minimis aid received in the course of the last three accounting periods:
Provider
Date of aid provision
Provided amount in EUR
Total sum for three accounting periods in EUR
Accounting period
Start date of the accounting
Last date of the accounting
period
period
1.
2.
3.
9
Select only one option
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The applicant is obligated to notify CzechInvest if other aid is provided during the period between
submission of the application and signing of the contract.
CzechInvest reserves the right to verify the accuracy and veracity of all of the above-mentioned
information.
In
, date
2012
………………………………………
Applicant’s signature
[Persons authorised for signing according to the Commercial Register and statutes or stamp, as
the case may be]
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