INNOVATORS APPLICATION FORM-2019

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APPLICANT DETAILS

LAST NAME *

As it appears in your ID/passport

FIRST NAME *

As it appears in the ID/passport

OTHER NAME (S)

As it appears in the ID/ passport

YOUR ID Number *

GENDER *

Female

Male

YOUR HOME COUNTY *

YOUR EMAIL ADDRESS *

YOUR MOBILE NUMBER *

THIS APPLICATION IS FOR *

Select one and DO NOT make two applications

LEADERS IN INNOVATION FELLOWSHIP - 2019

NATIONAL INNOVATION AWARD - 2019

NAME OF YOUR AFFILIATE INSTITUTION *

(Name of the Institution eg. university, Innovation /Incubation hub, Research Institution or TVET Institution)

AFFILIATE INSTITUTION ADDRESS *

AFFILIATE INSTITUTION TELEPHONE NUMBER *

ABOUT THE INNOVATION

(Describe your innovation based on the guidelines given below)

Title of the Innovation *

Is your innovation protected? *

Yes

If protected, please give the type of Intellectual Property protection and certificate number

Indicate the Technological Sector / Category/ Thematic Area of your Innovation *

Medical Technologies and Health Solutions

Built Environment and Housing Technologies

Agricultural and Food technologies

Energy Systems

Manufacturing, Engineering and ICT

Which Sustainable Development challenge does your innovation seek to address? *

Agriculture and food security

Sustainable Health and well-being

Inclusive and equitable quality education

Clean air, Water and sanitation

Affordable, reliable and Sustainable energy

Resilience and action on environmental shocks and change

Sustainable cities and communities

Reduce conflict and promote peace, justice and humanitarian action

Reduce poverty and inequality, including gender inequalities

What is the stage of your innovation? *

IDEATION STAGE

PROTOTYPE STAGE

DEVELOPMENT AND PILOT STAGE

FINAL PRODUCT

MASS PRODUCTION

Define the problem that your innovation seeks to address (Max. 100 Words). *

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 (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)]

Describe the target market for your innovation and perceived needs for your customers (Max. 70 Words): *

Describe the expected Socio-economic benefits and impact of your innovation (Max. 150 Words) *

Describe the major risks and challenges that you will have to overcome in taking the innovation business idea forward (70 Words) *

For this innovation, have you ever obtained cash award, grant or raised commercial investment capital before? *

Yes

If yes, describe the source, amount and the year

TRAVEL PASSPORT DETAILS REQUIRED FOR THOSE APPLYING FOR LEADERS IN INNOVATION FELLOWSHIP PROGRAMME

Your Passport Number, Date of Issue and Date of Expiry

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 *

My Passport size photograph (A MUST for all applicants)

A copy of my Travel Passport (ONLY for Leaders in Innovation Fellowship Programme Applicants)

A signed and stamped Letter of Recommendation from my Affiliate Institution (A MUST for all applicants)

A copy of my ID (A MUST for all applicants)

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 *

I fully agree to be bound by the declaration above and by any other conditions provided by KENIA.

Required

YOUR FULL NAME *

DATE *

YYYY

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