DISF Application Form

SECTION 1: EXECUTIVE SUMMARY

Name of solution*

Summary Description:*

Please provide a summary description of your product/ idea, the problem or need you are trying to solve and what you intend to achieve with the seed funding. This is the ‘elevator pitch’ that succinctly describes what your solution does (Max 1000 characters)

Total Funds Required*

Total Funds Requested from this fund*

Duration of support needed*

Maximum intervention window of 1 year

SECTION 2: PERSONAL DETAILS

Title:*

Name:*

First Last

Identity Number:*

Cell number:*

Work / Landline:*

Email*

Website*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Nationality:*

South African citizen/permanent resident
Non-South African

Biography:*

Please provide a short biography of yourself / team / company (500 characters)

SECTION 3: STUDENT DETAILS (IF YOU ARE A STUDENT)

Name of tertiary institution:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Does the tertiary institution have rights to your IP?

Yes
No

SECTION 4: BUSINESS DETAILS (IF YOU ARE A BUSINESS)

Company Name (if applicable)

Company Registration Number (if applicable)

Valid Tax Clearance Certificate?

Yes
No

If Yes, please submit.

Max. file size: 64 MB.

Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Number of employees (if applicable)

Turnover in the last year (if applicable)

How many years have you been in business?

BEE status or percentage black ownership

If below level 6, how could you improve this score? (Max 1000 characters)

Company Description:

Please provide a brief description of your company’s core business and products (if applicable) e.g. manufacture and sell lollipops (max 2000 characters)

Company Vision:

Please provide a brief overview of your vision for your company/idea and how this could support job creation and economic development (max 2000 characters)

SECTION 5: SECTOR

Please identify the sector into which the project falls

Agriculture – which might include production, process, product innovation or even compliance innovation

Agriculture

Advanced Manufacturing – which might include production, process, product innovation or even compliance innovation

Advanced Manufacturing

Health & Bio-tech – which might include production, process, product innovation or even compliance innovation

Health & Bio-tech

Alternative Building Materials – which might include production, process, product innovation or even compliance innovation

Alternative Building Technologies
Green Building Technologies

Water Conservation Technology – which might include production, process, product innovation or even compliance innovation

Water Conservation Technology

Information and Communications Technology – which might include production, process, product innovation or even compliance innovation

Information and Communications Technology

Energy Technology – which might include production, process, product innovation or even compliance innovation

Energy Technology

Other: please specify

Activities	Duration	Start Period	End Period	Deliverables	Budget

Funder Name	Amount Received	Activity funded	Period of Funding	Current Status (e.g. In Process, Completed etc.)

Name of funding institution approached	Application Amount	Activity proposed	Date of application	Current Status (e.g. Pending, Refused etc)

Team member	Qualification	Experience	Involvement (e.g. paid service, partner etc.)

Potential risk	Probability of Occurrence	Impact of Problem	Level or significance of risk	Cause	Planned Action

DISF 6 Application Form

SECTION 1: EXECUTIVE SUMMARY

SECTION 2: PERSONAL DETAILS

SECTION 3: STUDENT DETAILS (IF YOU ARE A STUDENT)

SECTION 4: BUSINESS DETAILS (IF YOU ARE A BUSINESS)

SECTION 5: SECTOR

SECTION 6: ACTIVITY

SECTION 7: SOLUTION

SECTION 8: INTELECTUAL PROPERTY POSITION

SECTION 9: PLAN AND BUDGET

SECTION 10: COMMERCIALISATION

SECTION 11: TEAM

SECTION 12: RISKS

SECTION 13: NATIONAL BENEFITS

SECTION 14: SUPPORTING INFORMATION

SECTION 15: SUPPORTING INFORMATION

SECTION 16: DECLARATION

Current/alternative offerings in the market	Features of current/alternative offerings (mention the most important advantages and disadvantages of current offerings)	Competitive advantage: any superior features that you have over your competitors’ offerings/current offerings

Partners	Role/ contribution to product/ idea	Agreement in place? Y/N