The Furnace Application Formpage 1 of 4

The Furnace
A Foundry for Digital Entrepreneurs
Application Form

Particulars of Applicant

Name:
(Underline Last Name)
NRIC No.: / NUS Staff No.:
Fin No.: / NUS Student No.:
NUS Affiliation: Academic Staff Graduate Student Undergraduate Alumni
(Select your option)
Faculty & Department: / Study Programme & Year of Graduation:
Residential Address:
Postal Code ( )
Mobile No.: / Tel No. (Residential):
Email Address:
Name of Company:
Company’s Website:
Applicant’s Main Role in the Company:
Company’s Present Location (if it is already formed):

Information of the Company

a)Type of Company (formed or would be formed):
(Select your option)
Limited company Partnership Sole proprietorship
b)The company is a/an
i)Independent start-up from NUS
If yes for (i), please indicate the department/faculty:
ii)Spin-off from a research grant
If yes for (ii), please complete the following:
Research Project Title
WBS Number
Funding Agency
Name of Principal Investigator
Department/Faculty
c)Has the company registered under Accounting and Corporate Regulatory Authority (ACRA)?
(Select your option)
Yes No
If yes, please attach a copy of BizFile.
d)Please attach individual Curriculum Vitae (max. of two pages) of Key Personnel(Partners/Directors/Shareholders/Key Employees). Please also include the Key Personnel’s designation and work commitment (full-time or part-time) in the Curriculum Vitae.
Total number of full-time staff / Total number of part-time staff
e)Projected Number of Staff (all-inclusive: Tech/Business/Admin):
Projection / Full-time Staff / Part-time Staff
After 6 months
After 12 months
After 18 months
f)Please attach a business proposal (max. of 10 pages) with the following points:
You may not need to follow the points in sequence.
i)Current business model
ii)Description of technology/system/product, business development and customers
iii)Type of technology and development status
iv)Patent or software/system license
v)Marketing strategy
vi)List the organizations in similar area of your technology/system/product
vii)Possible collaborator or industrial partner
viii)Deliverables over next 6 months
ix)3 year goals
x)Projection of quantum of investment
xi)Revenue received through sales, grants, awards, etc.
xii)Organizational structure
g)Have you turned to other sources for assistance to incubate your company?
You may choose more than one if appropriate.
No
Approached another incubator
Approached high-risk venture capital funds
Approached other sources
If yes to any of the above options for question 2g, please specify:

Declaration

I declare that the information provided is true and complete to the best of my knowledge.
By filing up this form, I hereby agree and consent that the personal data provided in this form and attachment may be collected, used, processed and disclosed by NUS for Innovation & Entrepreneurship activities related in accordance with the Personal Data Protection Act 2012 and all subsidiary legislation related thereto. I understand that NUS may disclose the personal data to third parties (which may be in or outside of Singapore) where necessary for the activities related.
I declare and warrant that for any personal data of the contract disclosed by me in this form and attachment, I have, prior to disclosing such personal data to NUS, obtained the appropriate consent from the individual whose personal data is being disclosed, to permit NUS to collect, use and disclose such personal data for the activities related.
Name / Signature / Date
Please complete all sections of the form (indicate “Nil” or “NA” where appropriate) and submit to

The Furnace Application FormPage 1 of 4