LEADERS IN INNOVATION FELLOWSHIP PROGRAMME - 2018
ABOUT YOUR SELF
Email address *
LAST NAME *
As it appears in your passport
FIRST NAME *
As it appears in the passport
OTHER NAME (S)
As it appears in the passport
NATIONALITY *
YOUR AFFILIATE INSTITUTION *
(Name of the Institution eg. university, innovation /incubation hub, Research Institution or TVET institution)
Upload a Letter of Recommendation from your Affiliate Institution (University, Incubation Centre or Innovation hub, Research Institution or TVET Institution) *
Required
YOUR EMAIL ADDRESS *
HOME ADDRESS
INSTITUTIONAL MAILING ADDRESS *
INSTITUTION TELEPHONE NUMBER *
YOUR MOBILE NUMBER *
Upload your Passport-sized photograph *
Required
Upload your Curriculum Vitae (Should NOT Exceed Two pages) *
Required
ABOUT THE INNOVATION
(Describe your innovation based on the guidelines given below)
Title of the Innovation *
Is your innovation protected? *
If protected, please give the type of Intellectual Property protection and certificate number
Indicate the Technological Sector / Category/ Thematic Area of your Innovation (eg. Health, housing technology, ICT, Agriculture..... etc) *
Define the problem that your innovation seeks to address (Max. 100 Words). *
Which sustainable challenge does your innovation seek to address? *
Required
Describe the benefits of your innovation in line with the National Development Agenda (Max 150 words) *
What is the stage of your innovation? *
What are the lessons that you have learnt from your innovation journey that may benefit your peers? (max 50 words) *
YOUR BUSINESS IDEA/PLAN
(This section is about market, scalability of the Product (good or service) and the socio-economic impact)
Give a one-line description of your innovation (Max. 15 Words) *
(This will be used to showcase your innovation. (i.e. what it is, who is it for, how it will change the world]
Describe the target market for your innovation and what are your perceived needs for your customers (Max. 70 Words): *
Provide a short description of your business idea. (Max. 100 Words) *
Describe the expected Socio-economic impact of your innovation (Max. 50 Words) *
Describe the major risks and challenges that you will have to overcome in taking the innovation business plan/idea forward (70 Words) *
Have you ever obtained a grant or raised commercial investment capital before? *
If yes, describe the source, amount and the year
ADDITIONAL DOCUMENTS
Your ID Number *
Scanned copy of the ID Card *
Required
Your Passport Number
Copy of your Passport page with biodata
DECLARATION
This is to declare that:
1. The information I have provided is accurate and is my original work;
2. I understand that if I participate in the programme, it is entirely my responsibility to provide all the relevant and mandatory documents.
3. I have submitted a copy of valid travel passport or shall submit a copy of valid travel passport within three weeks from the submission deadline of this application form
4. That I will allow the Kenya National Innovation Agency to share the provided information with its partners and stakeholders for the purposes of preparing for the Programme, monitoring, evaluation and reporting.
5. I am / shall be affiliated to an Institution for purposes of product development and/ or innovation commercialization.
6. I understand that:
(i) In case I am declared a finalist for the programme:
a) I’ll be available to participate in a two-weeks training and coaching session in the United Kingdom;
b) After the two weeks training and coaching session, I’ll return to Kenya, prepare a viable business plan for my innovation and submit the plan to KENIA within two-weeks after my return for application of Commercialization Grant;
(ii) In case I am declared a finalist for Commercialization Grant:
a)The Grant will be used for purposes of innovation development and innovation commercialization;
b)The Grant will be channeled through my affiliate institution;
c) I shall be providing progress and final reports as per the requirements of KENIA through my affiliate institution.
By ticking the check box *
Required
YOUR FULL NAME *
DATE *
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