CNSI Technology Incubator Application

The following application has 7 sections:

Company Contact Information
Organizational Structure and Affiliation
Financial Status and Incubation Timing
Technology
Incubator Space Utilization Plan
Safety / Compatibility
Certification

To help expedite the evaluation process, please provide as much detail as possible. It is easiest to complete this application on a computer.

1. Company Contact Information

Company Name*

Street Address*

City*

State*

ZIP*

Company Website

Contact/Representative Name*

Contact/Representative's Role at Company*

Contact Email*

Contact Phone Number*

2. Organizational Structure and Affiliations

Is the company incorporated?*

Select

Date of Incorporation*

Expected Incorporation Date*

Note that only incorporated entities are eligible to lease space in the CNSI Technology Incubator.

Entity Type*

Select

Entity Type if Other*

State of Incorporation*

US state where the company is incorporated

Corporate members*

List all executive officers, board members, and corporate advisors and briefly summarize their roles

US Citizenship*

Are all company founders and employees that will be working in the incubator U.S. citizens or residents? (Citizenship is not a requirement for participation in the program)

Select

UCSB Technology?*

Is the company based on UCSB technology or IP?

Select

UC Licensee?*

Is the company currently licensing or optioning UC IP?

Select

UC Connection?*

Are any of the company founders, officers, or key collaborators UC faculty, students, post-docs, or alumni?

Select

UC Connection details*

Please list the names and prior UC roles of founders, officers, or collaborators with a UC connection.

Concurrent employment*

Do any of the company's employees hold a concurrent appointment at UCSB?

Select

If any employees (including founders, advisors, or board members) hold an active appointment at UCSB, a letter describing how conflicts of interest will be avoided will need to be submitted along with the business forms.

If "yes" please list names*

3. Financial Status and Incubation Timing

Current funding status*

Select

Entrepreneurship award*

Please provide additional details on this funding

Government grant(s) type*

e.g. SBIR Phase I

Government grant agency(ies)*

Grant period(s) of performance*

Other; please explain*

Foreign investment*

Are any of the investments in the company originating from foreign (non-US) sources?

Select

Desired start date at CNSI*

Please note that application processing takes 3-4 weeks from the time all required business forms are received (including EIN, W9, and certificates of insurance).

Estimated residency time at CNSI*

*Please note that membership in the CNSI Technology Incubator will be limited to two years, extendable up to a 4-year maximum tenure in 1-year increments, pursuant to the sole discretion of the CNSI Technology Incubator advisory committee.

Select

Motivation*

Describe the benefits of the CNSI Technology Incubator Program to your company

4. Technology

Companies will be listed on the CNSI Technology Incubator webpage as a way of communicating the benefit of the program to CNSI stakeholders at and outside of UCSB. Answers to these two technology questions will help determine alignment with CNSI's mission. Answers should be broadly understandable and should not contain any confidential information.

Technology*

Provide a brief overview of the company's technology; what are you working on?

Company Mission*

What is the company's mission statement? What problem does the technology / product solve?

5. Incubator Space Utilization Plan

Desired space in the incubator*

At the initiation of the lease. Amendments to the lease to accommodate company growth may be possible, depending on availability of space.

Select

Number of bench stations*

Companies are limited to a maximum of 2 bench stations and a single fume-hood station, or 2 fume-hood stations and a single bench station.

Select

Number of fume-hood stations*

Companies are limited to a maximum of 2 bench stations and a single fume-hood station, or 2 fume-hood stations and a single bench station.

Select

Number of desks*

*Companies are limited to 2 desks. If there is a strong need for a third desk and there is availability, companies may lease a third desk on the understanding that they may be required to reduce their footprint with a 30-day advanced notice.

Select

Incubator Lab Occupancy*

How many people will be working at the incubator lab?

Equipment*

List any instrumentation/equipment that will be brought into the incubator lab (function, size).

Floor space explanation*

What equipment will require dedicated floor space? What is the size (including access space) required for this equipment?

Servers*

Does the company require space to hold/host a dedicated server?

Select

External footprint*

Will the company be using additional facilities/workspace off campus?

Select

External space description*

Please describe off-campus space used by the company

Shared Facilities*

Will the company leverage any Shared Experimental Facilities at UCSB?

Select

Other facilities not listed above*

6. Safety / Compatibility

Hazards*

Select

Chemicals*

Specify chemicals to be used (e.g. chemical name, chemical concentration)

Toxic or pyrophoric compressed gasses*

Specify gasses

High pressure reactors/vessels*

Specify reactors/vessels

Biological Hazards*

Select

Biological Hazards*

Please provide additional information about these hazards

Other biological hazards not listed*

Radioactive materials or X-ray producing machines*

Specify sources

Non-ionizing radiation*

Specify sources (e.g. power, wavelength)

Engineered nanoparticles/materials*

Specify materials

Controlled substances*

Specify substances

Other hazards*

Specify hazard(s)

ITAR/EAR*

Does any of the work you plan on conducting as a tenant of the CNSI Technology Incubator have a defense related application or involve military inputs or outputs (International Traffic in Arms Regulations (ITAR) or Export Administration Regulations (EAR))?

Select

7. Certification

Certification of Application*

By checking the box below, I hereby certify under penalty of perjury that the information provided within this application and accompanying business plan is true and complete to the best of my knowledge.

Name and title*

Name and title of individual completing application

Email*

Email of individual completing application

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