EmailMe Form - Proof of Concept Application Form

Title:

Name: *

First Last

Company Name: *

Job Title: *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email *

Phone Number: *

### - ### - ####

Cell Phone Number:

### - ### - ####

Industry Categorization: *

How much cash has been invested in the business to-date? *

Please indicate sources of investment(s): (check all that apply)

Other Sources of investment:

How much cash are you seeking at this time?

Are you interested in pursuing a high-growth business strategy which may involve raising money from outside srouces, including venture captial and other funds? *

Yes

No

Not Sure

Are you aware that taking outside capital will result in decreased equity? *

Yes

No

Is your company minority-owned or managed? *

Yes

No

If yes, please specify Minority Group (see Federal definitions):

Is your company woman-owned or managed? *

Yes

No

Including yourself, how many full-time employees work for the company? *

We only work with businesses located in South Dakota. By selecting yes, you confirm you are either currently located in South Dakota or will agree to relocate here as needed. *

Yes

No

Project Description

Please attach a project description including the following sections. Please limit the project description, excluding biographical sketches, budget and letters, to no more than five pages.

Summary: Provide a brief description of your company/product/idea and indicate what makes it unique (200 words or less).

Background: List and briefly describe the objectives. Briefly review the current
status of the proposed work and include any pertinent IP status(disclosure, ownership, licensing arrangement, etc.), commercial interest,
preliminary data and competition or barriers to market entry.

Work Plan: Clearly and succinctly describe the tasks to be done, identify who will do each task and provide a timeline for completions of each task with milestones used to determine success.

Commercialization Plan: Outline our plan for bringing the innovation to market, identify partners you plan to work with and include documentation of their interest or potential interest if your proof of concept research is successful. Clearly identify the economic impact on South Dakota’s economy in terms of job creation, partnerships with existing SD firms, etc.

Biographical Sketch: One page bio for each participant.

Budget: Up to $25,000
Detailed itemized budget.
Include budget justifications for items including identification of individuals salary, wages and
benefits to be supported with funds, equipment purchases, materials and supplies and contractual costs including patenting costs requested.
Document 10% cost share-equity
Salaries for owners of the company are not allowed.

Letters: Letters of commitment and support from investor and commercialization partners are required.

File Upload *