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Government of India

Department of Scientific and Industrial ResearchTECHNOPRENEUR PROMOTION PROGRMME (TePP)

Phase-I: Micro Technopreneurship Support (TS)

Application form

1. Title of the proposed project:

2. a. Name of the applicant :b. Fathers name/Husbands name:c. Postal address:

d. Nearest Railway Station &District Headquarters:

e. Profession of the applicant

Housewife

Student

Farmer(Please tick _/ as applicable) Any other _ _ _ _ _ _ _ _ _ _ _ _(specify)

f. Date of Birth: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _YY/MM/DD

g. Educational status: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

h. Completed (relevant) Project work /Documented knowledge in case of

farmer/ housewife(for students 'No Objection Certificate' from the institute to be enclosed)

i. Annual Income of the applicant:(If you are an Income Tax Payer, please provideyour PAN No. and attach a copy of the latest Income Tax Returns you filed)

3. My big idea is (Please use a separate sheet )

Present :

Permanent :

1. Please provide Pin Code, Telephone numbers, Fax and e-mail address, if any2. (Please enclose residence certificate issued by Sub-Divisional Magistrate(SDM)/District

Magistrate(DM) or a copy of ration card or any other document regarding proof of residence.

2010-2011

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4 (a). What have I done till now; participation in competition making a model provisional application for Patent paper presentations, publication,

college project.

(b) What I propose to do in future with TePP support and how will I do it;(Please use a separate sheet)

(c) What will be shown as result, at the end of the project

(d) Who would need this innovation and why?(Please use a separate sheet)

5. Proposed costs and time frame

Sl.no.

ItemsProject Cost

OwnShare

TePPsupportsought

1 Cost of raw material2 Amount to be paid to supporting

agencies3 Any other

Total Cost

Project period in months:________________________

6. Have you received financial support / award for your present work ?(if so, please furnish details)

7. Declaration :I declare that all the statements made in this application are true, completeand correct to the best of my knowledge and belief. In the event of anyinformation, found false or incorrect, my candidature will stand cancelled andall my claims will be forfeited.

Place: Signature of the applicant

Date:

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Evaluation by Technology Angel

1.Name of Expert :(e-mail ID, mobile no., contact address):

2.Name of Innovator :

3.Proposal title :

Part A ( to be filled first by innovator and later by expert)

4.Expert comments on proposed innovationInnovator(to be completed by innovator)

Expert(to be completed byexpert)

Description ofworking of theinnovation( use sketch,

drawing, model,photograph,video to explainthe working)

Description ofscience behindthe innovation

Relationship withthe projectwork(s)completed ineducationalinstitute by thestudent(s)

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Part B ( To be filled by expert only)

5.Expert comments on proposed innovation (Part B)Expert comments

Assessment onmerits of idea

Technologicalcapabilities ofinnovator tocomplete theproject asprojected

Recommendations

to TePP

[Signature of Expert with seal]

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No Objection Certificate for student innovators

The student innovator ------------------------- is ------------- studying in our institute

since.. . The institute has no objection to the student innovator

taking up the development work as proposed with financial support under

TePP. The institute labs will be made available on chargeable basis to the

student innovator for executing his/her TePP project.

Competent authority

.................................

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Covering letter to the TePP application

date..

To:

TePP Outreach Centre------------------------------------

Sub : Proposal for development of ..

Dear Sir/Madam

I am herewith submitting my application for support under TePP. The followingdocuments are enclosed.

Signed copy of application,

Proof of residence,

My big idea is.,

Documentary proof of prior work ( video, photo, press coverage etc)

Work planned,

Profile of potential user.

Technology Angels evaluation form ,.

Innovator