CRDF 1

COMMERCIALISATION OF R&D FUND

Commercialisation of Public and Private University / Government Research Institute R&D by a Spin-Off Company (Syarikat Terbitan University, STU) APPLICATION FORM

I.

PROPOSED PROJECT TITLE

For Office Use

II.

COMPANY PARTICULARS

Name of Company Registration Number Date of Incorporation Date of Operation

Address

Telephone Number E-mail Address

Fax No.

Factory Address (Current or proposed)

Telephone Number E-mail Address Contact Person Designation Telephone No. E-mail Address Latest Annual Sales Turnover (RM) (If applicable) RM Home

Fax No.

Mobile

Full Time Employees (For current figure)

Management : Technical :.

III.

PROJECT COSTING FOR 2 YEARS (Please provide details in the Commercialisation Plan) Estimated Cost of the Proposed Project (RM) Amount Applied for the Proposed Project (RM)

Reference For Office Use Section/Page

Item A. Infrastructure i. Cost of Land ii. Cost of Building B. Equipment i. Quality Control ii. Production iii. Maintenance

Not Applicable Not Applicable

C. Administration and Overheads i. Allowances for Management Staffs ii. Allowances for Technical Staffs iii. Office Rental iv. Telephone & Broadband v. Electricity vi. Water D. Cost of Technology i. Cost of Technology ii. Cost of Consultation iii. Cost of Training E. Intellectual Property Protection & Registration / Certification / Standards i. Cost of IP Registration and Protection ii.Cost of Product Testing and Standards iii.Cost of Registration of Certification F. Cost of Production i. Core raw material ii. Raw material for packaging iii. Cost of Production Outsourcing iv. Commercial product design v. Packaging design G. Advertisement, Marketing and Promotion i. Brochure ii. Exhibition

iii. Advertisement iv. Website Design and Development v. Product Launching H. Others (please specify) Not Applicable TOTAL

IV.

PROPOSED FINANCIAL STRUCTURE (Please provide details in the Commercialisation Plan) Source RM %

Reference For Office Use Section/Page

Estimated Grant from CRDF Loan from Bank Shareholders Advance Venture Capital Others TOTAL 100 %

V.

DECLARATIONS

a. Have you or your company applied for Government funding prior to this application? NO / YES (Please give details) ____________________________________________________________________________________________

b. Have you or your company been connected (directly or indirectly) with an application for Government funding prior to this application? NO / YES (Please give details) ____________________________________________________________________________________________

c.

Have you or your company had previous dealings with MTDC (Grant/Investment/Consultancy/Incubation and Nurturing) prior to this application? NO / YES (Please give details) ____________________________________________________________________________________________

d. For this application, have you or your company appointed or intends to appoint consultants to be part of your Key Management or Technical Team? NO / YES (Please give details) ____________________________________________________________________________________________

e. Have you or any directors, shareholders or employees of your company ever been a director, shareholder or employee of a company which had winding-up proceedings or receiving order made against it in Malaysia or overseas? NO / YES (Please give details) ____________________________________________________________________________________________

f.

Are you or any directors, shareholders or employees of your company an undischarged bankrupt or committed any act of bankruptcy as defined under Section 3 of the Bankruptcy Act 1967? NO / YES (Please give details) ____________________________________________________________________________________________

g. We hereby declare that this application form including the Business Plan was prepared by :Mr/Ms/Miss : .. who is an : Employee or Appointed Consultant of the company (please give details) ____________________________________________________________________________________________

h. This section shall be signed by an individual who is legally and duly authorised by the company. We understand and declare that: i) We have read, understood and agreed to abide the CRDF Guidelines For Applicants; and ii) We warrant that all information, data and documents in this application are true and correct and all other information in writing which has been given by the company (or any of its directors, officials or advisors) to MTDC in the course of this application, presentation and negotiations was , when given, true, complete and accurate in all material respect AND THAT the Company is not aware of any fact or matter and after making due and careful enquiries, not disclose in writing to MTDC which renders any such information untrue, inaccurate or misleading or the disclosure of which might affect the willingness of MTDC to process the application for consideration of the grant scheme.

Name NRIC No. Designation Name of Company Signature Date Companys Official Stamp

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