INNOVATORS APPLICATION FORM-2019
APPLICANT DETAILS
LAST NAME *
As it appears in your ID/passport
Your answer
FIRST NAME *
As it appears in the ID/passport
Your answer
OTHER NAME (S)
As it appears in the ID/ passport
Your answer
YOUR ID Number *
Your answer
GENDER *
YOUR HOME COUNTY *
Your answer
YOUR EMAIL ADDRESS *
Your answer
YOUR MOBILE NUMBER *
Your answer
THIS APPLICATION IS FOR *
Select one and DO NOT make two applications
NAME OF YOUR AFFILIATE INSTITUTION *
(Name of the Institution eg. university, Innovation /Incubation hub, Research Institution or TVET Institution)
Your answer
AFFILIATE INSTITUTION ADDRESS *
Your answer
AFFILIATE INSTITUTION TELEPHONE NUMBER *
Your answer
ABOUT THE INNOVATION
(Describe your innovation based on the guidelines given below)
Title of the Innovation *
Your answer
Is your innovation protected? *
If protected, please give the type of Intellectual Property protection and certificate number
Your answer
Indicate the Technological Sector / Category/ Thematic Area of your Innovation *
Which Sustainable Development challenge does your innovation seek to address? *
What is the stage of your innovation? *
Define the problem that your innovation seeks to address (Max. 100 Words). *
Your answer
What are the lessons that you have learnt from your innovation journey that may benefit your peers? (max 50 words) *
Your answer
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 (NOT more than 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)]
Your answer
Describe the target market for your innovation and perceived needs for your customers (Max. 70 Words): *
Your answer
Describe the expected Socio-economic benefits and impact of your innovation (Max. 150 Words) *
Your answer
Describe the major risks and challenges that you will have to overcome in taking the innovation business idea forward (70 Words) *
Your answer
For this innovation, have you ever obtained cash award, grant or raised commercial investment capital before? *
If yes, describe the source, amount and the year
Your answer
TRAVEL PASSPORT DETAILS REQUIRED FOR THOSE APPLYING FOR LEADERS IN INNOVATION FELLOWSHIP PROGRAMME
Your Passport Number, Date of Issue and Date of Expiry
Your answer
SUBMISSION OF DOCUMENTS
Check the relevant boxes to confirm that you shall submit in one folder the following documents before application deadline via email to: secretariat@innovationagency.go.ke *
Required
BINDING 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 my National ID Card;
4. As an applicant for Leaders in Innovation Fellowship, I have submitted a copy of valid travel passport or shall submit a copy of valid travel passport within two weeks from the submission deadline of this application form;
5. 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;
6. I shall be affiliated to an Institution for purposes of product development and/ or innovation commercialization.
7. In case I am declared a finalist for the Leaders in Innovation Fellowship programme, I understand that:
a) I shall be available to participate in a two-weeks training and coaching session in the United Kingdom;
b) The training cost, return air ticket to UK and back to Kenya, accommodation and subsistence during the two- weeks programme will be catered for under the Newton Fund partnership programme;
c) I shall personally cater for my Visa application cost and any other own personal costs;
d) After the two weeks training and coaching session, I shall return to Kenya.
e) Upon return, I should prepare a viable business plan for my innovation and submit to KENIA within fourteen (14) days for evaluation and possible consideration to be a finalist and recipient of Commercialization Seed Grant;
8. In case I am declared a finalist and recipient of either National Innovation Award or Commercialization Seed Grant, I understand that:
a)The granted funds are public funds provided by the Government to support and nurture innovative capacity;
b)The funds shall be used for purposes of product development and/or innovation commercialization;
c)The funds shall be channeled through recognized affiliate institution;
d) 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 *
Your answer
DATE *
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