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1. Applicant details Denotes a required field. Please select your Partner Country
English skills P l e a s e c h e c k t h e b o x w h e r e a p p r o p r i a t e a b o u t y o u r l e v e l o f E n g l i s h s k i l l s Speak Beginner
Intermediate
Advanced
Intermediate
Advanced
Intermediate
Advanced
Intermediate
Advanced
Fluent Understand Beginner Fluent Read Beginner Fluent Write Beginner Fluent Your ambitions for the programme (250 words maximum) What do you hope to get out of the Leaders in Innovation Fellowships programme? Which areas and activities do you expect to be supported by your country partner organisation? Describe which aspects of the programme will be particularly valuable to you in commercialising your innovation, and explain why.
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Applicant(s) Contact Details: Please provide the name of the lead applicant, institution and preferred correspondence details. Please include the dialling code when entering your mobile phone number. Please enter your full name according to your passport.
MsMahmodaAli Lead Applicant 0207 7660642 (Work)
[email protected] (Work) Prince Philip House, London, SW1Y 5DG, Great Britain (Work)
NB you must provide full contact details before this page will be flagged as complete.
Participating Institution details:
Do you have a valid international passport for travelling abroad? Yes
No
If yes, please enter your passport expiry date.
Are you free to travel to London, UK between 26 Nov- 10 Dec 2016? Yes
No
Preferred Name Please give your preferred first name(s) and surname(s). This will be printed on your name badge and certificate of completion.
Short Biography Please give a brief summary of the lead applicant's career and achievements. We will use these biographies within the introductory pack for participating Fellows and to be placed in materials for wider circulation and publicity of the Leaders in Innovation Fellowship programme. Please avoid over complicated language and keep the text simple. Page 2 / 8
Please upload a photograph. Please upload a passport-sized photograph of the lead applicant. We will use this photo within the introductory pack for participating Fellows and to be placed in materials for wider publicity of the Fellowship programme so please ensure it is suitable and professional. File name
Date uploaded
Please upload your CV(s) The format and content of your CV is left to your discretion. Your CV should not exceed two (2) pages, and should be uploaded electronically as a PDF document. File name
Date uploaded
CVs should be 2 pages maximum. Special or Dietary requirements Please notify us of any allergies or special dietary requirements you might have (that is, are there any particular foods that you cannot eat). This information will help us with ordering meals during the training.
Special Assistance Do you require any special assistance during the residential training due to a health condition or disability? Yes
No
Please specify the assistance you will require This information will help us to ensure the venue, hotel and transport are fully accessible and suitable to the participant's needs.
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2. Your Innovation Denotes a required field. Title: Give a brief title to the name of your innovation, or the name of your proposed business. Project title:
Technological sector or research area. Please select the major technological sector or research area that your innovation derives from. If it fits into more than one area please choose the one which is the most relevant.
About your innovation/product/service Please give a description of the particular science or technology that underpins your (proposed) business.
For example, what is the problem that your invention is intended to solve? Why is the proposed solution better than other existing solutions? Why are improvements necessary or desirable? How close in terms of development is the technology, product or service t o m a r k e t? W h at fu r th e r d e v e lo p m e n t is re q u i r ed ? Does your innovation promote economic development and/ or social welfare development in your country? Yes
No
Benefits of your innovation One of the broader aims of the Newton Fund is to promote economic and social welfare development in developing countries. Please outline the potential benefits of your innovation in terms of promoting economic growth and/or improving health and social wellbeing.
What is your stage of technology development? Concept/idea
Prototype
Laboratory development
Final product
Mass production
What is your IP Status? Currently no IP protection
PCT/international patent filed
No IP protection planned Page 4 / 8
National patent filed
Copyright
What are the next steps you are working on for your innovation?
What is the biggest challenge you are facing at the moment?
Are there any lessons that you learned from your innovation that you would like to share with your peers?
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3. Your Business Plan Denotes a required field. One Line Pitch
We will use this one line to showcase your innovation in networking events etc. Business Summary Please provide a short description of your business idea.
Stage of your innovation Please select the option which best describes the stage of development of your product 1. Idea
2. Laboratory Demo
4. Final Product
5. Mass Production
3. Prototype
Source of Funding Please select the option that indicates the source of funding you are next seeking for your business/project 1. Research grant
2. Proof of concept funding
4. Scale up funding (for expansion)
5. Other
3. Seed funding (for operations and manufacturing)
Have you ever raised commercial investment capital before? Yes
No
Do you intend to raise commercial capital in the near term? Yes
No
Business Profile Please fill out the table with relevant or available details, for the categories:
Number of Researchers/Employees Current or potential investors Page 6 / 8
Partners Total Capital Raised Total Capital Pursued Grants/Awards received Next steps Please select the option which best describes what you are looking for next: Commercialising my innovation myself (Spinout/Start-up)
Licencing my innovation
Sales Strategy Please select the option which best describes the sales strategy of your business 1. Market research
2. Speaking to 1st potential customer
3. Route to market secured
4. Working with confirmed sales partners Customers and their perceived needs Please give an outline of who you think will be the customer for your new product, technology or service, and their perceived needs. What problem do they have that will be solved by the innovation? What evidence is there that customers will pay for this product or service at commercially profitable levels?
Major risks (100 words) Please identify what you think will be the major risks and challenges that you will have to overcome in taking the business plan forward (e.g. lack of funding or securing intellectual property).
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4. Declaration Denotes a required field. Applicant Declaration Please declare that: The information you have provided is accurate. You understand that if you participate in the programme, it is entirely at your own risk. It is the responsibility of all participants and/or their employers to arrange suitable travel insurance befo re participants travel to the UK for the residential programme. You understand that it is your responsibility to obtain the necessary visa to travel to the UK. That you will allow the Royal Academy of Engineering to share this material with its Fellows and subcontractors for the purposes of preparing the training for the Leaders in Innovation Programme. Confirm that you have permission from all relevant employers to attend the Fellowship, if selected to participate. I confirm that I have the permission of any person or persons I have included contact details for, to share their details with the Royal Academy of Engineering for the purposes of administering this application. Name and position:
By ticking this checkbox I agree to be bound by the conditions for this scheme.
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