applicaton form

Please complete the form below to begin the application process. Note the required fields marked by the (*)

BUSINESS INFORMATION
Business Name:
Principal Officer(s) and Title:  
Telephone: Fax:
Email:  
Current Business Address:  
Form of Ownership:  
Corporation        Partnership          Sole Proprietor
   

Nature of Business (brief description of product/service and nature of market):
   
Brief Background of Principal Officer(s):
   
Date Business Established:  
   

Current Status of Business (e.g., working on prototype, product in advanced development, etc.):
   
Current Sales Revenue (please indicate dollar volume per month):
$  
   

Number of Employees (include principal officers): 

 
Full Time: Part Time:
   
Projected Number of Employees Within 12 Months: 
   

Type of Financing Used to Operate Business to Date:

Personal Resources        Venture Capital Firms            Private Investors         Other
Indicate Nature if Other:   
   

Status of Business Plan:

Business Plan Completed           Business Plan in Preparation - To be Available By: 
Business Plan Not Started
   
Do You Need Help Writing a Business Plan?
Yes            No  
   

Approximate Space Requirements:
Square Feet for Office
Square Feet for Lab
Other (Please Specify) -
None – My company will be a non-resident affiliate.

 

  
Special Facility Requirements (electrical, ventilation, floor load, etc.):
Approximate Date You Desire To Occupy Space :
   
DSTA FUSION GRANT APPLICATION

Are you interested in applying for a DSTA Fusion Grant?
Yes            No  
   
What do you propose to use the grant funds for?  
   
What is the amount of the grant that you are seeking?
 
   
When do you need the funds?  
   
Please explain your financial need for grant funding from DSTA.
   
Submitted By:
Name:
Title:
Date:
Where did you hear about us?

   
 


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