CT Next Assessment Form - BBC Entrepreneurial Training & Consulting LLC

Name*

Preferred Email*

Phone*

Company/Organization (if formed)*

What is your title within the company?*

In what year was the company formed? (if appropriate)*

Address*

What is your NAICS code? (To find your company’s NAICS code, search: http://www.naics.com/search)*

Please indicate if your company is:*

Women owned
Minority owned
Veteran owned
Other

Are you collaborating with other organizations on your proposed SBIR/STTR project (e.g., academic laboratories, etc.)?*

Yes
No

If not, have you identified prospective collaborators?

Yes
No

If yes to either of the above, please identify:

In the past 12 months...

Has the company received any other funding from Connecticut Innovations or any state partners or accessed other State of Connecticut resources? (Examples include but are not limited to awards through: CI’s Pre-Seed Fund, Small Business Innovation and Diversification Program, Technology Talent Bridge program, Eli Whitney Fund (equity investments), and SBIR Acceleration and Commercialization Program; SBDC offices, incubator grants, CTNext, SCORE and DECD’s Small Business Express Program.*

Yes
No

If yes, please name the funding organization(s) or agency(s) and the amount(s).

Has the applicant or any of the company principals been sued in civil court for a debt in the past 12 months?*

Yes
No

If yes, please explain:

Does the applicant or company owe any outstanding city/town/municipal taxes for the past 12 months? (This includes both business and residence.)*

Yes
No

If yes, please explain:

Federal Eligibility Requirements

Does your company fulfill the following SBIR/STTR eligibility requirements?

Is your company:*

<500 employees
>51% owned by individuals who are US citizens and/or permanent residents
Majority owned by another small business that is majority owned by US citizens and/or permanent residents
Majority owned by institutional investors (e.g, venture capital, hedge funds)
A subsidiary or affiliate of another organization

Do you have company-controlled research space?*

Yes
No

If no, have you identified space that you will move into at the time of award?

Yes
No

If yes to either of the above two questions, please describe your company facilities and identify their location:

Have you identified a Principal Investigator (PI) who will be 51% employed by the company at the time of award?*

Yes
No
We plan to do an STTR and have identified a PI at a collaborating institution

Briefly describe the background and qualifications of the PI:*

Tell us about your SBIR/STTR Project

Please answer the following questions that relate to your SBIR/STTR project and related technology/product:

Which Federal Agency(ies) do you plan to apply to?*

National Institutes of Health (NIH)
National Science Foundation (NSF)
Dept. of Defense (DoD)
Dept. of Energy (DoE)
U.S Dept. of Agriculture (USDA)
Other (please specify)

Please specify any other agencies to which you plan to apply:

Briefly describe the technology/product to be developed:*

What is the ownership status of your IP?*

My company owns the IP
A university or other entity owns the IP
N/A

Please check all of the following that apply to your technology?*

Patent application submitted
Patent issued
We have trade secrets or other intellectual property (IP)
N/A

What unmet need do you plan to address with your innovation?*

What is unique about your proposed product?*

Who is the intended customer for your product?*

Who are your competitors? Are you aware of competitive technologies?*

Briefly describe your commercialization strategy, e.g., how do you anticipate getting your product to market?*

Briefly describe if you own, license or are on a path to controlling your intellectual property.*

Previous SBIR experience

Has your company ever applied for SBIR/STTR before?*

Yes
No

Has your company received any SBIR/STTR awards?*

Yes
No

Briefly describe any previous/current SBIR/STTR awards:*

How would you describe your proposal-writing experience?*

No previous proposal-writing experience
I've helped people write proposals
I've written proposals before but not SBIR/STTRs
I've written unsuccessful SBIR/STTRs
I've written successful SBIR/STTRs

Have you attended SBIR/STTR training before?*

Yes
No

If yes, please provide the date(s) and topic(s):

Have you identified an Agency and solicitation? What is the submission deadline?*

Is there anything else you would like to add?

Please attest that above information supplied is true and accurate by adding your name and title.*

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