Capital - Application - Information Technology

PROPOSAL COVER PAGE

BEN FRANKLIN TECHNOLOGY PARTNERS

OF SOUTHEASTERN PENNSYLVANIA

INFORMATION TECHNOLOGY

2010-2011 INVESTMENT PROPOSAL

APPLICATION

For:____________________________________________________________

Company Name

Funding under this program is made possible by the Commonwealth of Pennsylvania

PROPOSAL COVER PAGE

INFORMATION TECHNOLOGY COMPANY INVESTMENT APPLICATION

BEN FRANKLIN TECHNOLOGY PARTNERS OF SOUTHEASTERN PENNSYLVANIA

PROPOSAL TITLE:

Name of Principal Contact Person:Title:

Organization: Telephone: Ext.

Address: City:_______________________________

State:_____________ Zip:_________ - ________ Mobile or Home Telephone:

Fax:______________________E-Mail: Web Site Address: __________________

Provide Address(es) for All Other Business Locations (if applicable):

___________________________________________________________________________________

Participating Organizations: Name all companies, schools, and other institutions participating in the project, along with each participating organizations address:

Participating OrganizationAddress

___________________________________________________

___________________________________________________

___________________________________________________

Amount Requested from BFTP: $*

Total Project Budget:$*

*Please make sure these amounts match those listed on your project budget sheet.

Please select the one technology category into which your project most closely fits.

Software

Hardware

Telecommunications

Web Services

Is your company currently working with nanomaterials or nanoprocesses? Yes No________

Does the Project described in your BFTP application involve the use and/or commercialization of nanomaterials or nanoprocesses? Yes No________

Disclaimer: The submission of the proposal shall not create any rights on behalf of the submitter, contractual or otherwise. The submission of a proposal does not constitute or create any legally binding or enforceable agreement or commitment on the part of the Ben Franklin Technology Partners of Southeastern Pennsylvania (BFTP-SEP) other than to maintain the confidentiality of proposal information identified as confidential. No past or future action, or course of conduct by BFTP-SEP, will give rise to or serve as a basis for any legally enforceable duties or obligations on BFTP-SEP other than to maintain the confidentiality of proposal information identified as confidential.

Signature of Authorized Official at Applicant Company:

Signature: Date:

Type or Print Name and Title:

TABLE OF CONTENTS

When you have completed your proposal, please assemble it in the order shown below, number the pages consecutively, and fill in the page numbers on this sheet. Include all pages in your proposal.

Proposal Cover Page 1

Table of Contents 2

Applicant Company Information 3

I. Non-Confidential Executive Summary 4

II.Scientific and Technological Aspects of the Project ________

Needs Statement________

Background ________

C. Proposed Program of Work ________

D. Data ________

E. Resources ________

F. Qualifications of Personnel ________

G. Previous Work ________

III.Intellectual Property________

IV.Management________

V.Commercialization Aspects of the Project ________

Please note: a company business plan may be substituted for sections IV and V only. Sections I and II must be completed in full though we encourage you to lift portions of the business plan to complete these sections as appropriate.

A. Market Analysis ________

B. Competitive Analysis ________

C. Marketing, Sales, Distribution, and Customer Service________

D. Senior Management________

E. Board of Directors or Advisors________

F. Production ________

G. Protection and Timing of Proprietary Rights________

H. Regulatory, Clinical, or Other Approvals________

I. Pennsylvania Job Creation________

VI.Financial Information ________

A. Actual Financial Statements ________

B. Summary Financial Projections________

C. Capitalization Plan and Follow-On Funding________

D. Current Capitalization Table________

VII.Milestones ________

VIII.Budget________

IX.Appendices________

A. Letters of Commitment from Funding Sources ________

B. Technical Data/Citations________

C. Resumes/Curriculum Vitae________

1. Management

2. Board of Directors

3. Advisors

4. Principal Scientists

D. Market Research Summary________

APPLICANT COMPANY INFORMATION

Important: Complete all items on this page.

Please supply the following information for the Applicant Company. BFTP is required to provide this information to the Ben Franklin Technology Development Authority.

General Information:

Company name:

Company federal I.D. number*:

State or country of headquarters:

Parent company, if division or subsidiary:

State, month, and year of incorporation:

Type of corporate entity (S-Corp, C-Corp, etc.):

Foreign Owned: ________Yes ______No Location:_______________________

Woman-owned: _____Yes _____No Minority-owned: _____Yes _____No

NAICS Code:_________ or Primary industrial activity:

Who recommended you apply to BFTP for funding: ________________________

Location Information:Number of Employees:

PA County:Pennsylvania:

Township:Worldwide (including PA):

Borough:

PA Legislative District or Legislator:

PA Senatorial District or Legislator:

US Congressional District or Legislator:

County Code: (Bucks 09, Chester 15, Delaware 23, Montgomery 46, Philadelphia 51)

Municipality Code (if known):

Are you located in a Keystone Innovation Zone (KIZ)? _______Yes______No

Project Information:

Please select items in each column that best describe your project:

Innovation Type

Innovation Form

Expected Project Outcome

Innovative Application of Existing Technology

Product

Pre-Prototype/R&D

New Technology

Service

Prototype

Process

Product/Prototype Testing

Commercialization/Product Launch

Expected Pennsylvania Jobs Within Company:

During ProjectYear 1Year 3Year 5

* The request for the federal I.D. number is necessary to track participation of companies in various programs of the Pennsylvania Department of Community and Economic Development. Similar company names can cause confusion, but each company's I.D. number is unique.

I. NON-CONFIDENTIAL EXECUTIVE SUMMARY

(Not to exceed four pages)Target Reader: Non-Technical

Please provide, written in the third person, a concise yet comprehensive executive summary that will serve as an overview of the company. It is not required to follow the outline below but please be sure to include all of the information requested.

Business Overview

Describe the business mission and revenue model.

Describe the technology, current products and if there is a pipeline, include a table listing the products, proposed uses and stage of development. Briefly describe the technology platform, if applicable.

Describe the sales and marketing efforts/results to date, including any key customers/strategic partners. Please include date commercialization began and/or is scheduled.

Describe key product features and competitive advantages.

Market Opportunity

Briefly describe the overall relevant market. Define the companys target segment(s).

Quantify the size and growth characteristics of the target segment(s).

Briefly identify key direct and indirect competitors.

Describe the sales and distribution channels to be used.

Key Personnel

List key management and very briefly describe their roles, including level of commitment (part-time, full-time), skills, education, and relevant experience.

List members of the Board of Directors and Advisors and briefly describe their level of commitment, skills, relevant experience and whether they are or have been compensated to some degree with equity.

Intellectual Property

Describe any significant Intellectual Property, if any, the company currently owns, has filed for or licenses, and/or expects to do so within the next year.

Funding

Describe the companys funding history to date, e.g. current capital structure, key investors, and amounts invested in both cash and in-kind contributions.

Describe the expected and confirmed source(s) of match for the BFTP funds.

I. NON-CONFIDENTIAL EXECUTIVE SUMMARYcontinued

Project Overview and Expected Outcome

Assuming BFTP funding, briefly describe the key technical milestones, with expected dates, that you expect to achieve during the Project period, and over the next year (if different), and indicate what the key subsequent steps will be.

Using some measurable outcomes, such as revenues, customers, beta sites, products or processes commercialized, number, type and location of employees, intellectual property filed, etc., describe the commercialization progress you expect the company to achieve during the Project per