HIP2 Application Form – Islamic Innovation Challenge 2019

ISLAMIC INNOVATION CHALLENGE 2019

HIGH IMPACT PROGRAMME 2 (HIP2)APPLICATION FORM

PROJECT TITLE:__________________________________________________________________

Please submit 1 hard copy and 1 soft copy of this form. All information required in the project must be filled up/provided. PlaTCOM will share the Applicant’s audited financial statement with

Agensi Inovasi Malaysia and SME Corp Malaysia for the purpose of monitoring and evaluation of HIP2.

For office use onlyDate received: _______________

PlaTCOM Ventures Sdn Bhd3501, Level 3, Quill Building 3,

Jalan Teknokrat 5, 63000 Cyberjaya,Selangor

Tel: +603-83193116Fax: +603-83193499

www.platcomventures.com

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HIP2 Application Form – Islamic Innovation Challenge 2019

SECTION A: COMPANY DETAILS

Part 1: Applicant Details

Company Name:_____________________________________________________________

Company registration number:_____________________________________________________________

Date of Incorporation:_____________________________________________________________

Date of commencing business:_____________________________________________________________

Authorised capital: ________________Paid-up capital: ________________

Structure of shareholding:

Shareholder Name

% of shares No. of shares Share values (RM)

Nationality

TOTAL:

Malaysian: Bumiputera Non-bumi

Foreign:TOTAL:

Sector: (Please refer to attached guidelines. e.g. ICT, Manufacturing, etc.)____________________________________________________________________________________________________________________________

Women entrepreneur: Yes____ No____

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HIP2 Application Form – Islamic Innovation Challenge 2019

Core Business Activities:1.____________________________________________________________2.____________________________________________________________3.____________________________________________________________

Business address:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Company’s directors:__________________________________________________________________________________________________________________________________________________________________________________________

Contact person:______________________________________________________________

Designation: ____________________Contact No.: ____________________Fax No.: ________________________Email: ________________________________________________________Website:______________________________________________________

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HIP2 Application Form – Islamic Innovation Challenge 2019

Past Financial Track Record:

i. Please provide latest financial statements (latest audited accounts)Items 2018 2017 2016Total Local SalesTotal International SalesTotal Operating ExpendituresTotal Profit / (loss) Before TaxTotal R&D spending

ii. Previous innovations by the companyProject Title Brief description Current status Commercialised?

When? Revenue to date? If no, why?

iii. Please state if your company is currently a recipient of, or have previously received any funding from AIM/PlaTCOM and/or other Government Ministries or agencies. If yes, please provide the following details:

Type/Name of fund

Ministry/Agency Project title Year received

/duration

Grant Amount

Completed?*

*If not completed, please provide details on current status of the project*If completed, please provide the letter of acknowledgement of completion received from the grant authority

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HIP2 Application Form – Islamic Innovation Challenge 2019

Part 2: Collaborator Details

Do you have a collaborating party? Yes ____No____ (if No go straight to Section B)

Our collaborator is: ________________________________________________________

Please tick (X) for collaborator category:

Start-up companySpin-off companySmall companyMedium/large companyPublic listed companyGovernment linked companyInstitution of higher learningGovernment research instituteIndividual

Name of collaborating party/ies:________________________________________________________________________

Office Address:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Project Leader Name & Designation:________________________________________________________________________

Project Members Name & Designation:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Contact No.: __________________________ Fax No.: _________________________

Email: ____________________________

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HIP2 Application Form – Islamic Innovation Challenge 2019

Brief background of the collaborating party:________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

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HIP2 Application Form – Islamic Innovation Challenge 2019

SECTION B: PROJECT PROPOSAL

Part 1: Project Details

Project Title:________________________________________________________________________________________________________________________________________________

Problem Statement: (Please provide the problem statement and describe the rationale for the proposed product in meeting market demands and addressing problems faced by the market)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Description of Technology Solution:

a. Description of the Technology (Product and/or Process) and how it addresses the problem statement.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

b. Technology Applications.__________________________________________________________________________________________________________________________________________

c. Provide the approaches, technologies used to develop the proposed product. Provide methodologies/process flow of the proposed solution.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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HIP2 Application Form – Islamic Innovation Challenge 2019d. Comparison between R&D/Lab prototype and proposed commercial scale: (Please

tick your current status of the project with the details as below and expected details on the nest stage/s).

Idea R&D/Lab prototype

Pilot Scale Commercial Scale

e. Comparison with other competing technologies:

Item Proposed solution

Competitor A Competitor B

ApplicationFeaturesPrice/CostDisadvantagesAdvantagesDisadvantagesOthers…..

f. Project deliverables.__________________________________________________________________________________________________________________________________________

g. Intellectual property rights:

Application No. Filing Date Status Applicant name

Inventor name

PCT National phase

h. Standards, certifications & regulatory compliances.

No. Description StatusObtained In process To be obtained

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HIP2 Application Form – Islamic Innovation Challenge 2019

i. Project risks:

Type of Risks Risk Details Mitigating PlanMarketTechnologyFinancialHuman Resources

j. Project benefits to the organisation and Malaysia:

Social benefits: __________________________________________________________________________________________________________________________________________

Economic benefits:__________________________________________________________________________________________________________________________________________

k. Project milestone and activities:

No. Milestones Activities1.2.3.4.5.…

l. Project Gantt chart (Please attach as per example below):No. Tasks Durations W1 W2 W3

1 Task 1 2 weeks2 Task 2 4 weeks3 Task 3 4 weeks4 …… 2 weeks5 …… 2 weeks

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HIP2 Application Form – Islamic Innovation Challenge 2019

m. High Impact Programme 2 facilitation sought: Please fill up whichever applicable

No. Scope of Facilitation Support Needed from PlaTCOM

(1) Licensing support

(2) IP filing (patent, trademark, ID)

(3) IP strategy

(4) Branding

(5) POC/prototype

(6) Productisation

(7) Testing and validation

(8) Technical assistance

(9) Regulatory certification

(10) Legal advisory

(11) Market intelligence

(12) Funding (CCGF) If yes, please complete Section B, Part 2.

(13) Funding (external)

(14) Market access including lining up clients

(15) Business planning

(16) Commercial/corporate advisory

(17) Technology scouting

(18) Marketing collaterals/website

(19) Halal consultancy

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HIP2 Application Form – Islamic Innovation Challenge 2019

Part 2: Concept to Commercialisation Gap Fund (CCGF) AssistancePlease itemise and provide breakdown for expenses of each component and sub component you have identified

No. EXPENSESITEMS and

JUSTIFICATION

COST

(RM)

TOTAL

(RM)

CCGF

(RM)

Own Fund

(RM)

1.POC & prototype development

(The details below are examples only)

i. Technical Improvement

-Circuit layout optimization

-Miniaturization of device

-Trouble shooting

ii. Material costs

-Electronics components (LCD, sensors, other peripherals) (50 sets)

-Power supply modules (5 sets)

-Microprocessor (20 units)

-Printed Circuit Board (10 units)

iii. Rapid Prototyping

-Casing parts (5 units)

-Casing materials

i. 50,000

ii. 75,000

iii. 25,000

150,000

2.

Productisation

i. Finalization of industrial prototype for 5 units

-Fabrication cost

-Material cost

-Packaging design- Product customization for ICT based project

i. 100,000

100,000

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HIP2 Application Form – Islamic Innovation Challenge 2019

3. Licensing support

Licensing fee for Patent from University XX for:

i. Patent A

ii. Copyright B

i. 30,000

ii. 10,000 40,000

4.Testing & validation

i. Product Testing by Accredited Testing Lab:-

-Performance Test (RM10,000)

-Reliability Test (RM10,000)

-Electrical Safety Test (RM10,000)

i. 30,00030,000

5. Regulatory

Product Certification Test to meet:- i. MS Standard

ii. ISO XXX

iii. IEC YYY

i.50,000

ii. 25,000

iii. 25,000100,000

6.Technical assistance

i. Consultancy Services by Local Expert on Electronic Sensor

i. 50,00050,000

7.Sector-specific market intelligence

i. Frost & Sullivan Market Report 2015 on Electronic Sensors Market

j. Surveys ?

i. 15,00015,000

8.Incubation services

i. TPM Incubation Office Rental Fee for 1 year (RM2,000 per month)

i. 24,00024,000

TOTAL PROPOSED PROJECT COST 509,000 509,000

TOTAL TO BE FUNDED BY CCGF 356,300

TOTAL OWN FUNDING COMMITMENT TO PROJECT

-Secured

-Unsecured

100,000

52,700

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HIP2 Application Form – Islamic Innovation Challenge 2019

Project Team (Describe the technical and business capabilities, qualifications and experience of project team members. Please attach CV of each team member)

i. Name:Organisation:Highest Qualification:Role:Experience:

ii. Name:Organisation:Highest Qualification:Role:Experience:

iii. Name:Organisation:Highest Qualification:Role:Experience:

iv. …..

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HIP2 Application Form – Islamic Innovation Challenge 2019

Part 3: IP Licensing / Technology Acquisition Details (if applicable)Please leave blank whichever not applicable.

Would your project require acquiring IP rights? Yes ___ No___ (If no, please proceed to Section C)

IP/Technology Title.________________________________________________________________________________________________________________________________________________

IP/Technology Description (commercial potential etc.)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Type of acquisition – Please tick whichever applicable:

Outright AcquisitionLicensingOthers (Please describe)

Intellectual Property Rights Details:

Application No. Filing Date Status Applicant name

Inventor name

PCT National phase

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HIP2 Application Form – Islamic Innovation Challenge 2019

Cost of IP/Technology Acquisition:

No. Expenses Items Cost (RM) Total (RM)1. Acquisition of

IP/Technology2. Training (technology

transfer)Total Cost of Acquisition

Novelty of IP/Technology to be acquired.________________________________________________________________________________________________________________________________________________

Proposed IP/Technology Acquisition Date.________________________________________________________________________

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HIP2 Application Form – Islamic Innovation Challenge 2019

SECTION C: Market & Financial Information

Part 1: Market Potential

1.1 Market Need.________________________________________________________________________________________________________________________________________________________________________________________________________________________

1.2 Market Size & Potential.________________________________________________________________________________________________________________________________________________________________________________________________________________________

1.3 Addressable Market Size & Potential.________________________________________________________________________________________________________________________________________________________________________________________________________________________

1.4 Price Competitiveness.________________________________________________________________________________________________________________________________________________________________________________________________________________________

1.5 Industry Competitors.________________________________________________________________________________________________________________________________________________________________________________________________________________________

1.6 Barrier to Entry.________________________________________________________________________________________________________________________________________________________________________________________________________________________

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HIP2 Application Form – Islamic Innovation Challenge 2019Part 2: Financial Projection for 5 YearsPlease elaborate extensively by providing basis and assumptions used

2.1 Financial Forecast

2.1.1 Cash Flow

2.1.2 Income Statement

2.1.3 Balance Sheet

Part 3: Capacity and Capability to CommercialisePlease elaborate extensively

3.1 Financial Resources________________________________________________________________________________________________________________________________________________________________________________________________________________________

3.2 Marketing Strategy________________________________________________________________________________________________________________________________________________________________________________________________________________________

3.3 Distribution Network________________________________________________________________________________________________________________________________________________________________________________________________________________________

3.4 Business Model________________________________________________________________________________________________________________________________________________________________________________________________________________________

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HIP2 Application Form – Islamic Innovation Challenge 2019Part 4: Declaration

This form must be signed by the Project Leader and endorsed by the CEO/MD.

I / We certify that:

The information provided in this application, including attachments, is true and correct to the best of my / our knowledge.

Project Leader:

Name:

Designation:

Signature: Date:

CEO/MD:

Name:

Designation:

Signature: Date:

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HIP2 Application Form – Islamic Innovation Challenge 2019

Form Checklist

No. Items (Tick)

i. Duly signed of this Project Proposal Form

ii. Certified true copy of form 9. Form 24, form 44, form 49 and M&A of the company

iii. Certified true copy of Company’s latest audited account/management accounts for the last three (3) years

iv. CVs of all project personnel referred to in Section B: Part 2 of this Project Proposal Form

v. Other attachments (i.e Gantt Chart, Detailed Financial Projection and Assumptions, supporting documents such as Letter of Intent, Licensing Agreement etc.)

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