Incubatee Application Form 2024

A. PERSONAL INFORMATION

1. Name of the Applicant

2. Date Of Birth

3. Gender

Male Female Prefer Not to Say Other

4. Nationality

Indian Other

5.Contact Address with Phone Number

6. Web-Site

7. E-mail

8. Education

9. Any Additional Professional Qualification or Certificates

10. Name of College

11. Verification Proof

12. Work Experience

13. Company Name & Type (Private/ Public/ LLP/ Sole Ownership)

14. Partners/Directors

B. STARTUP STATUS

1. You have a novel idea/ concept and hope to convert it in to a commercially viable product/ services through support/ R&D collaboration with HABIT Foundation

Yes No

2. You hope to become a new Pharmaceutical/ Science/ Technology/ Engineering/ Arts/ Law/ Management/ other entrepreneur in 02 years

Yes No

3. You own/ represent a Start-up Company engaged in a Pharmaceutical/ Science/ Technology/ Engineering/ Arts/ Law/ Management/ other business in which expertise/ research interest exists in HABIT Foundation

Yes No

C. START-UP IDEA / BUSINESS DETAILS

1. Title of your Business proposal for association with HABIT

2. Brief Description of the Product/Services/Business you plan

3. Brief description of the requirements and other inputs you hope to resource from HABIT Foundation

Infrastructure Capacity Building 󠆸 󠆸 Technical Mentoring 󠆸 Business Mentoring 󠆸 Regulatory & Advisory Services 󠆸 IP Facilitation 󠆸 Networking Funding Other

4. Have you interacted with the concerned faculty and has he/she/they consented to collaborate with you? (If Yes, give their names with contact details)

5. Have you prepared a Business Plan? If yes, please submit a copy.

6. Please indicate your sources of funds (if any)

7. Profile of your Company, if already registered. (Type of business, details as date of registration etc. membership of stock exchange if any, key personnel/associates, specific achievements etc.)

8. Mention about any Patent filled/ Grant received/ Prototype developed/ Proof of Concept.

9. Please give names and address of up to 2 referees who are acquainted with your career profession/ achievement.

10. Any other detail, which would help in evaluating your proposal

11. Date

12. Place