Innovation Voucher Application

Contact Information

Legal Company Name*

Name*

First Last

Job Title*

Email*

Office Phone*

Mobile Phone

Qualifying Questions

Innovation Voucher targets eligible Indiana small businesses. Do you currently meet or are you willing to meet these requirements?*

General eligibility requirements:

is authorized to transact business in Indiana;
maintains a majority of its business operations within Indiana; and
employs not more than one hundred fifty (150) persons.

Yes

Please name the Indiana higher-ed or nonprofit research institution you intend to partner with for this grant application.*

Enter Legal Company Name

Please name your project lead (main service point of contact) at the Indiana higher-ed or nonprofit research institution you intend to partner with for this grant application.*

General eligibility requirements: "Indiana institution of higher education" means a public or private college or university that:

is located in Indiana;
provides research services;
is willing to waive all internal overhead charges related to the contemplated research, and
is approved by the IEDC.

"Other authorized research provider" means a non-profit research organization, other than an Indiana institution of higher education, that:

is located in Indiana;
provides research services; and
is approved by the IEDC.

Project Title*

Project Start Date*

Project End Date*

Describe the problem that an Innovation Voucher Grant would address for your company.*

Describe the scope of the business need that an innovation voucher grant would address. What would be the scope of your requested project and how would that assist your company’s growth?

How would an Innovation-Voucher-supported project address your business need?*

Please describe impact on business performance and related financial outcomes

Please describe the proposed project deliverables to include deliverable title, description, start and end date, and cost associated with that deliverable.*

Please describe the total project amount to be paid to your nonprofit research provider, including sources and uses of funds. Payments in cash only. Do not include any payments in-kind or in equity.*

Amount requested from the Innovation Voucher Program, in dollars.*

Please attach a detailed project budget.*

Accepted file types: xlsx, docx, pdf, xls, doc, Max. file size: 10 MB.

Attach any additional supplemental materials below.

Accepted file types: xlsx, docx, pdf, xls, doc, Max. file size: 10 MB.

Company Information

Company Address*

Street Address Address Line 2 City State ZIP Code

Please provide a brief summary of your company, product, or idea.*

Limit 255 Characters

Company Website*

Company Structure*

Other Please Specify*

Industry*

Other Please Specify*

Date of Incorporation*

Number of Current Employees*

Number of Indiana Employees*

List any other Indiana higher-education institutions or other organizations assisting your business.

How much private capital have you raised?*

Is a principal of the company a U.S. military veteran, woman or minority?*

“Principal” is defined as founder or c-suite member with at least a 5% equity interest in the company.

Yes

Is the company veteran owned, controlled or led?*

The company has at least 51% veteran in its founding/management team or its current governance board or shareholder base, or the company is led by a veteran CEO. Veteran is a person who served on active duty with the U.S. Army, Air Force, Navy, Marine Corps or Coast Guard, for any length of time and at any place and who was discharged or released under conditions other than dishonorable. Reservists or members of the National Guard called to Federal active duty or disabled from a disease or injury incurred or aggravated in line of duty while in training status also qualify as a veteran.

Yes

Is the company women owned, controlled, or led?*

The company has at least 51% women in its founding/management team or its current governance board or shareholder base, or the company is led by a woman CEO

Yes

Is the company minority owned, controlled, or led?*

The company has at least 51% minority in its founding/management team or its current governance board or shareholder base, or the company is led by a minority group member CEO. “Minority” is defined based on race, ethnicity, and sexual orientation, including African Americans, American Indians and Alaska Natives, Asians and Pacific Islanders, Hispanics, and LGBTQ individuals.

Yes

How did you hear about us?*

Other Please Specify*

Please specify the referring organization and/or person.

Comments

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