IIMCIP



To apply for the incubation programme at IIM Calcutta Innovation Park, please fill the following information:

|Name Of Social Enterprise: | |

|Sector: (Mark YES in front of any ONE of the following; If ‘Others’, please specify): |

|Agriculture, Food, Diary | |

|Healthcare, Water and Sanitation | |

|Technology and Development | |

|Education | |

|Housing | |

|Handicrafts | |

|Energy | |

|Microfinance/Financial Inclusion | |

|Others | |

|Contact Details: |

|PRIMARY CONTACT PERSON (Should Be One Of The Full Time Founders) |

|Designation: |Email: |

|Mobile Number: | |

|Registered Address: | |

|Office Address (if different from above) | |

|Email | |

|Office Phone | |

|Website (if any) | |

|Legal Status of firm: (E.g. Sole Owner/ Pvt Ltd / Partnership) | |

|Registration number and date: Firm registration (as applicable) | |

|What problem are you trying to solve? |

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|Describe your offering (product or service) with key features, Explain how it addresses the need |

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|What is the social impact that your venture can generate? (Please support with numbers) |

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|Who is/are the END CUSTOMERS? and why they would use your product / service? |

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|Technology behind the core offering by the Start-up (tick applicable): |

|To be developed Self Developed Acquired / Licensed Off the Shelf |

|If Self Developed – technology development time & linkages used / is the technology Patentable / status of patent and-or application / countries where |

|applicable / if not yet patented what are the strategies for protection |

|If Acquired / Licensed – from whom & terms – conditions |

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|If Off the Shelf – comments on the ‘innovation’ from the startup |

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|Current Status |

|What is the current status of the business - ideation/ under development/ pilot| |

|launch/ revenue generation started etc . | |

|Do you have paying Customers? | |

|List your major customers / first adopters (if any) | |

|Details of all Founders |

|SL No |Name |Educational Qualifications (Std. passed / |Work Experience |Permanent Address |Contact: Phone, Mobile,|

| | |Degree, Year, University) |(Company, No. of Years, | |Email |

| | | |Functional Area) | | |

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