Proof of Concept

Proof-of-Concept Application FormTest the market potential of your idea and solution

By completing and submitting this Application form, I am applying for the support/services under the Proof-of-Concept Program that is implemented by the Technology Transfer Facility within the Innovation Fund (hereinafter: “PoC Program”), for my project entitled: ______________________________________________________________ (hereinafter: “Project”), Project ID number ___________ disclosed in the following Application form.

PoC Program tests, develops and advances your scientific idea coming from your research and commercialize it into a market-worthy product for the appropriate market niche.

IMPORTANT:

The PoC Application form is a written description of your Project. By entering correct and complete data in this form you help the Innovation Fund (hereinafter the “IF”) to properly evaluate your Project.

Information exchange between you and the Innovation Fund about your Project is confidential. To avoid any inadvertent public disclosure of your Project please use an appropriate Confidential Disclosure Agreement to protect discussions with others.

A completed PoC Application form should be submitted in electronic form through the official PoC Portal that can be accessed through the Innovation Fund

webpage or directly via PoC Portal. If you have any questions regarding the completion of the Application form please contact the Innovation Fund via email at PoC@inovacionifond.rs.

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Proof of Concept

PROJECT INFORMATION

1. GENERAL INFORMATION

Title of the Project (English):

Title of the Project (Serbian):

Project ID:

Name of the project leader/principal researcher:

Project leader’s/principal researcher’s home address:

Project leader’s/principal researcher’s email:

Project leader’s/principal researcher’s mobile phone no.:

Employer R&D organization:

Industry area:

All correspondence with, and questions for, the Project team will be addressed to the project leader/principal researcher.

2. OTHER TEAM MEMBERS

List the research team members that will actively contribute throughout this project. Team members from other (R&D) organizations could be included in the list. Make sure to include only those individuals whose input is critical for the project success. Individuals doing routine measurements and testing and not actively contributing to the project should not be included. External contractors that will be paid form budget category II. Experimental PoC should not be named as team members.

Team member’s name:

Team member’s home address:

Team member’s email:

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Role in Project:

Employer/ R&D organization:

Note: In case the team consists of more members insert the table below and fill in the data

Team member’s name:

Team member’s home address:

Team member’s email:

Role in Project:

Employer/ R&D organization:

3. PROJECT BACKGROUND

Existing Intellectual property in the moment of applying. Tick only if you have a particular right in place (approved or submitted patent, trademark or other IP right): patent ☐, trademark ☐, design ☐, copyright ☐, knowhow ☐, database ☐ other

Technology Readiness Level: 1 ☐, 2 ☐, 3 ☐ , 4 ☐ , 5 ☐, 6 ☐ , 7 ☐ , 8 ☐, 9 ☐Have you published any critical part of this Project (journal, thesis, poster…)? : Yes ☐, No ☐

Sum of the requested amount (Maximum 2,4M RSD):

4. ABSTRACT (Maximum 200 words)

The abstract should provide the reader with a clear understanding of the objectives of the Project proposal and how they will be achieved. The abstract will be used as the short description of your proposal in the evaluation process and in public communication by the Innovation Fund. It must therefore be short and precise and should not contain confidential information. It should be written in both English and Serbian language.

ENGLISH

SERBIAN

5. POC PROJECT PROPOSAL (maximum 700 words)

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Proof of Concept

This section outlines, in brief, the potential of the proposed innovative idea. It will be used as an assessment criterion. It should contain:

Description of the innovative concept – short description of the proposed action describing the innovation and what the expected deliverables are.

Potential of the innovation if the concept is proven – how will the proof of concept be used to create a product.

6. MAIN BENEFITS (up to 400 words)

This section outlines the main benefits for the society and/or economy of the proposed action. In addition, it should clearly state the main features of the proposed innovation.

7. IMPLEMENTATION PLAN (700 words + activity table)

This section describes the plan of implementation of the PoC grant, its main results and relevant risks. Activity table lists the particular activity, its duration and the period of implementation. Activities should be listed in the order of implementation starting from the first activity. Each activity must be described and any interrelation between the activities has to be noted in the description (e.g. activity 1 must be finalized before activity 2 starts, etc.).

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No.

Activity Description of the activity DurationFrom - to

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2

3

4

5

6

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8. PROJECT BUDGET

This section provides the Project’s budget divided in already predefined categories and should include the exact amounts per category as the PoC budget (excel form).

Maximum allowed budget is RSD 2.4 million including VAT. Most of the budget categories contain limits to maximum amounts that can be used for these categories. These limits must be complied with, as higher amount than the specified maximum will not be accepted. Each particular cost in the budget table must be related to one or more activities from the activity table. No indirect costs are allowed.

Costs Activity nr. Cost, RSD

Personnel costs (up to RSD 600,000.00)1

Experimental PoC including consumables, equipment/facilities rental or external experts (up to 1.2M RSD)

Travel, local and international (up to RSD 240,000.00)

Legal services (up to RSD 240,000.00)

Business adviser (up to RSD 480,000.00)

Other direct costs (up to RSD 120,000.00)

Total (RSD)

9. CVs OF KEY CONTRIBUTORS

1 Maximum amount per man-month (full time) cannot exceed gross RSD 120,000.005

Proof of Concept

CVs of the project leader/principal researcher, as well as short CVs of up to 5 team members, should outline the experience relevant to the proposed Project and be submitted on PoC Portal next to the Proof of Concept Application Form and Project budget.

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TERMS AND CONDITIONS OF THE PoC PROGRAM

For the purpose of this document, the terms “we” and “us” shall refer jointly to the Applicant (as defined in the PoC Program Guidelines) and the project leader/principal researcher (as identified in the PoC Application form), except when otherwise expressly stated.

1. USE OF DATA

We confirm that all the facts and statements in the Application form are true and complete.

We agree that the basic data about the Applicant, names of the Project’s team, as well as the data in the abstract of the PoC Application form, disclosed in English and Serbian language, can be made publicly available, subject to the Statement of Confidentiality attached in Annex 1 hereto.

We agree that the data in the Application form can be stored in the databases and used for the purpose of the implementation of the PoC Program and the purpose of statistical analyses (without technical details of the technology).

We agree that in case of support granted/successful commercialization, the data in the Application form can be used for promotion of the PoC Program (without revealing technical details).

2. INFORMATION REQUIREMENTS

We agree to provide all additional information to the Innovation Fund per request, needed for the evaluation, and monitoring of project in the phase of implementation.

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We agree to report in a timely manner any changes relevant for the Project implementation to the Innovation Fund, as the changes occur, and that in case such changes are not reported fully and timely, we will be jointly and severally responsible for any possible damages and costs that may result from it.

We confirm that we are familiar with any and all documents related with the PoC Program and we fully and irrevocably agree that any and all such documents related with the PoC Program will be binding for us and shall apply together with any agreement.

3. DECISION ON THE PROJECT SUPPORT

We understand that the decision whether the Project proposal submitted within the Application form will receive support under the PoC Program is made by the PoC Decision Committee at the Innovation Fund and that the Innovation Fund will consider the Applicant’s appeal to this decision only with respect to the (non)eligibility and the administrative (in)completeness of the Project.

4. INTELECTUAL PROPERTY (IP)

We understand that one of the expected results of the support of the Project through the PoC Program is to ensure that that no Project related intellectual property (including without limitation patents, patent applications, trademarks, trademark applications, trade names, brands, copyrights, service marks, know-how, or show-how, R&D results, etc.) - hereinafter: “IP” infringes the IP rights of any third party, which should be achieved preferably before the second disbursement, in accordance with the PoC Program Guidelines.

5. PROCUREMENT

We confirm and undertake to carry out the procurement of goods and services defined in the Application form in accordance with the Procurement Law of the Republic of Serbia.

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6. ENVIRONMENT

Environmental and social impact in the PoC Program is expected to be negligible due to the nature of the grants (some R&D and soft support services).

We understand and accept that in cases where the Innovation Fund’s program manager suspects potential negative impact of the Project, the environmental and social management specialist may be called upon to perform a detailed assessment and to advise on any safeguard issues, in which case the terms of the Environmental and Social Management Framework available online (www.inovacionifond.rs) will apply.

7. FRAUD AND CORRUPTION

We agree to adhere to the highest ethical standard throughout the execution of the financing agreement and implementation of the Project. For that purpose:

(i) “corrupt practice” is the offering, giving, receiving, or soliciting, directly or indirectly, of anything of value to influence the actions of another party;

(ii) “fraudulent practice” is an act or omission, including misrepresentation, that knowingly or recklessly misleads, or attempts to mislead, a party to obtain financial or other benefit or to avoid an obligation;

(iii) “collusive practices” is an arrangement between two or more parties designed to achieve an improper purpose, including influencing improperly the actions of another party;

(iv) “coercive practices” is impairing or harming, or threatening to impair or harm, directly or indirectly, persons or their property to influence their participation in a procurement process, or affect the execution of a contract;

(v) “obstructive practice” is:

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(a) deliberately destroying, falsifying, altering, or concealing of evidence material to the investigation or making false statements to investigators in order to materially impede a Fund or World Bank investigation into allegations of a corrupt, fraudulent, coercive, or collusive practice; and/or threatening, harassing, or intimidating any party to prevent it from disclosing its knowledge of matters relevant to the investigation or from pursuing the investigation, or

(b) acts intended to materially impede the exercise of the Innovation Fund’s inspection and audit rights.

8. CONFIDENTIALITY

We hereby confirm that we have read and agree with the Innovation Fund’s Confidentiality Statement and Prevention of the Conflict of Interest Policy (http://www.inovacionifond.rs/cms/files//o-nama-akti/Confidentiality_Policy_and_Prevention_of_Conflict_of_Interest_Policy.pdf).

We fully agree that nothing contained in the foregoing shall restrict the right of the Innovation Fund to make public the Innovation Fund's support to the Project and the identity the Applicant as the awardee in the PoC Program. The Innovation Fund shall keep confidential all information it receives from us. In case the Innovation Fund uses the assistance of a third party, which includes sharing confidential information, the Innovation Fund shall execute an appropriate confidential disclosure agreement with such third party and ensure the confidential information remains publicly undisclosed.

By signature below, we agree to be bound by these Terms and Conditions of the PoC Program

______________________________

Signature

Principal Researcher’s Printed Name

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APPLICANT: “University/Faculty/Institute” e.g. Faculty of Technology and Metallurgy

_______________________________

Signature Date:

e.g. rector or dean or director

Note: By signing this document you acknowledge that the above-signed Principal Researcher is employed/engaged with your organization.

Printed name

Stamp

Note: You can insert scanned page with signatures and stamps as picture

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Proof of Concept

The Innovation Fund of the Republic of Serbia, with its principal seat registered at 22-26 Nemanjina Street, Belgrade, the Republic of Serbia (hereinafter: “IF or Recipient”), represented by Dr Ivan Rakonjac, Managing Director, hereby assumes obligations defined under this Confidentiality Statement (hereinafter: “Statement”), in order to maintain confidentiality of confidential and proprietary information, technical data, trade secrets or know-how, including but not limited to research, product plans, products, markets, software, developments, inventions, processes, formulas, technology, designs, drawings, engineering, marketing, distribution, and financial figures disclosed to the Innovation Fund in connection with the Proof of Concept Program (hereinafter: “Purpose”), as well as any information as a result of evaluation of the information disclosed to the Innovation Fund, such as peer-review evaluation conducted by third parties (hereinafter: “Information”).

IN CONSIDERATION OF and as a condition of the disclosers providing the Recipient with Information within the Project and for the Purpose, the Recipient undertakes the following obligations.

1. Confidential Obligations . Recipient will keep Information in confidence and use it only for the purpose of evaluation and review. Except as expressly provided for in Section 3 (Required Disclosures) and Section 5 (Internal Dissemination) below, the Recipient shall not disclose or make Information available to any other person, institution or company or use the Information for any commercial benefit or any research purpose. Disclosers shall disclose their Information to Recipient in writing, marked “Confidential”, and in sufficient detail to enable Recipient to fully evaluate them. If Information is provided orally, visually or in another non-tangible form, the Information will be reduced to written form, marked “Confidential”, and submitted to the Recipient within thirty (30) days of disclosure.

2. Duration of and exceptions from Confidential Obligations . For a period of five (5) years from the date of disclosures received, the Recipient will treat the Information with reasonable care to avoid its disclosure to any person (natural or otherwise). Except as otherwise provided for herein, or by applicable law, the Recipient shall be generally liable for unauthorized disclosure or failure to exercise such reasonable care but the Recipient will not be so restricted with respect to any Information:

2.1 which are already known to the Recipient at the time of disclosure;2.2 which after disclosure, becomes part of the public domain, except through breach of this Statement by the Recipient;2.3 which the Recipient can establish, by competent proof, was in its possession at the time of disclosure;2.4 which the Recipient receives from third parties who are not obliged to maintain confidentiality of that Information;2.5 which is independently developed by the Recipient’s employees without use of the Information, as shown by competent proof;

or2.6 which is approved for release by written authorization of the discloser.

3. Required Disclosures . If the Recipient is required by applicable law, administrative or judicial order to disclose Information, the Recipient shall promptly notify the discloser of such fact so that discloser may attempt to obtain a protective order or other appropriate remedy with respect to any such disclosure. If any such order or other remedy does not fully preclude disclosure, the Recipient will make such disclosure only to the extent that such disclosure is legally required.

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ANNEX 1

STATEMENT OF CONFIDENTIALITY

Proof of Concept

4. Limited Use . Recipient has the right and obligation to use the Information only for the Purpose in accordance with this Statement and the Statement does not establish for the Recipient any sort of license, use, or any other rights in the Information.

5. Internal Dissemination . Recipient’s internal dissemination of discloser’s Information is limited to those employees, officers, directors, internal and external advisors whose duties justify the need to know such Information and all necessary efforts will be made by the Recipient to require its employees, officers, directors, internal and external advisors who have been given access to and who shall receive disclosures of the Information to maintain the strictest secrecy under this Statement.

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