NASA Adopt A City Program 2016 Application

NASA Adopt A City Program 2016 Application
Note: This application requires completion in one sitting. If you would like to review the questions prior to submitting this form, please download this document. If you have any inquiries about the application, contact Megan Tomsik at megan.tomsik@magnetwork.org.
Date of Submission*

MonthDayYear
Company Name*
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Company County*
Primary Contact*

First NameLast Name
Primary Contact Title*
Primary Contact Business Phone Number

Area CodePhone Number
Primary Contact Cell Phone Number*

Area CodePhone Number
Primary Contact Email*
Product Name*

Product Description/Market Environment
1. Please provide a brief (100 word or less), non-confidential description of your product.*
2. Who is the intended market for this product?*
3. What is this product's advantage over any competitive products?*
4. What intellectual property rights - if any - do you have regarding this product?*

Technical Challenge
5. Please briefly describe the technical challenge you are facing for which you are seeking assistance.*
6. What has been done to date to attempt to solve this problem, and what have been the associated outcomes? (Please provide details and attach additional information, if available, to end of this application.*
7. Outline how you envision a proposed solution might be achieved.*
8. What technical support do you believe is required to solve this problem? (Please trace it back to questions 6 & 7).*
9. Estimate the start and finish time of this project.*

NASA Core Competencies
10. Using this document as reference, please note which of the NASA core competencies most closely align with your technical challenge.
Air-Breathing Propulsion
Communications Technology and Development
In-Space Propulsion and Cryogenic Fluids Management
Power, Energy, and Storage Conversion
Materials and Structures for Extreme Environments
Physical Sciences and Biomedical Technologies
Other Basic Engineering Disciplines (Please Describe)

Anticipated Outcomes
11. In the event that the technical challenge that has been presented is solved...
a) What outcomes can be expected?*
b) What impact would you expect to see in revenue growth in 1 year? In 5 years?*
c) What impact would you expect to see in job growth in 1 year? In 5 years?*
12. In what other ways might solving this technical challenge benefit your company and the community (jobs saved, cleaner environment, etc.)?

Current Status
13. Is your product currently in production?*

YesNo
If yes...
13-Y1: Please state where the production is taking place (facility name and full address)
13-Y2: If production is currently taking place outside of Cuyahoga County, please describe the situation and any activities that are being planned to move manufacturing to the City of Cleveland or Cuyahoga County.
If no...
13-N1: What is the current status of development of this product? Include a brief description of the product development activities that have been completed thus far. (i.e. market research, product design, prototype development, product testing, market testing, etc.)
13-N2: Aside from solving the technical problem presented here, what else would need to be done before your product could be manufactured?
13-N3: Where do you anticipate manufacturing your product?
13-N4: Can you commit to manufacturing your product in the City of Cleveland?

YesNo
13-N5: Can you commit to manufacturing your product in Cuyahoga County?

YesNo
13-N6: What elements of the supply chain for your product are located in Northeast Ohio?

Funding
14. What was your company's revenue in 2015?*
15. Has your company received any external funding or investment for the development or commercialization of this product? If so, please describe.*
16. Do you wish to apply for a loan through this program?*

YesNo
IF YES:

16-Y1. Please upload a Project Description document.

If applying for funding, you are required to submit a brief 2 page or less project description.

Use the outline below to format your submission:
1. Project Overview - a brief summary description of the project and how you plan to use the loan funds.
2. Project Budget - identify loan amount requested (up to $50,000); itemize project activities/tasks and associated costs
3. Project Milestones/ Timeline - outline how the project will bring the company closer to commercialization
Funds may not be used for:
- General administrative overhead
- Travel
- Capital expenses
- Staff salaries
Save and submit your Word document or pdf file as "CompanyName_ProjectDescription"
Upload Project Description file

Upload a File

Cancelof
16-Y2: Will this project go forward if funding is not awarded through this program?

YesNo
Additional Information
You may upload up to FIVE (5) pages of additional supporting information.

This can pertain to any aspect of your application and may include product drawings, executive overview, etc. ONLY THE FIRST 5 PAGES of supporting information will be reviewed by the judging committee; anything beyond that will be discarded.

Save and submit your document your Word documet or pdf file as "CompanyName_SupportingInfo"

You can also submit a summary business plan (included in the 5 page limit). If so, please use the outline below to format your submission.
1. Business Overview – define the target market
2. Product/Service – define the technology intellectual property
3. Market Size Opportunity – identify exiting/projected sales
4. Financial Overview – sales and marketing strategy
5. Growth Funding Development Plan:
6. Management Team
17. Do you plan to submit additional information?*

YesNo
Upload Additional Information

Upload a File

Cancelof

Authorization
Please Note:
- Finalists may be subject to credit check prior to loan approval.
- All program participants will be required to provide periodic status updates throughout the duration of the program and for up to three years after the conclusion of the program.
- Loan recipients may be subject to additional terms as outlined by the City of Cleveland, Cuyahoga County, NASA and/or MAGNET.
- Employees of MAGNET, the City of Cleveland, Cuyahoga County, and NASA are not eligible to apply to this program.
I acknowledge and accept these terms and conditions.*

YesNo
Authorization

BY SIGNING THIS APPLICATION YOU CERTIFY THAT THE IDEAS, PRODUCTS, AND/OR PROCESSES DESCRIBED IN THIS APPLICATION ARE WHOLLY THE CREATION OF AND ARE OWNED BY THE APPLICANT. IF THE SIGNATURE SHOWN BELOW IS AN ELECTRONIC SIGNATURE, OR IS MADE BY MEANS OF A DEVICE OR MACHINE AND IS ANY NAME, INCLUDING A TRADE OR ASSUMED NAME, OR A WORD, MARK, OR SYMBOL LOGICALLY ASSOCIATED WITH THE APPLICANT (INCLUDING TYPING APPLICANT’S NAME ON THE SIGNATURE LINE), THEN, BY AFFIXING ANY OF THE FOREGING TO THIS APPLICATION, THE APPLICANT ACKNOWLEDGES AND AGREES THAT THE SAME SHALL HAVE THE SAME BINDING EFFECT AS IF THE APPLICANT MANUALLY SIGNED THE APPLICATION.
Authorization Signature*

First NameLast Name
Authorization Title*
Authorization Date*

MonthDayYear
Should be Empty: