Proof-of-Concept Program
APPLICATION FORM
GENERAL INSTRUCTIONS
Refer to the Proof-of-Concept Program Guidelines document for details of this competition and
the evaluation criteria for applications. Interested applicants are instructed to contact Genome
BC at [email protected] with any technical questions or clarifications. Genome BC will be
pleased to advise any applicants on how to complete this application.
Applications must be submitted online at http://programs.genomebc.ca/. The application form is
available on the Genome BC website (www.genomebc.ca) and must be used. The online
application format and requirements will be similar to what is described in the Proof-of-Concept
Program Guidelines and in this application form.
To be considered a completed application, the following must be submitted to Genome British
Columbia (Genome BC):


The application form and appendices (including budget) submitted online
Original signature pages for the Project Leader(s), Co-Applicants, and Participating
Organizations sent to the address below:
Proof-of-Concept Program
Genome BC
Suite 500, 555 West 8th Avenue
Vancouver, BC V5Z 1C6
All submissions must be clearly marked: Proof-of-Concept Program.
Except for the budget template, this Application must be presented as follows:




Arial font (regular), minimum 11-point
Text single-spaced
One-inch margin on all sides of each page
A header and footer on each page with the project title in the top left-hand corner, and
the page number in the bottom right-hand corner.
Completing the Form
Each field within the tables in this form will expand to accept more information by using the
return ( ENTER) key. If additional rows are needed in a table, place the cursor in the last field
of the last row and press the TAB key. If there are more than two (2) project leaders copy and
paste the project leaders contact information table directly below the first tables.
Version 5.0 June 30, 2011
Please remove the instructions on each page before submitting the application. Note that
the instructions do not count towards the page limits.
Information Sharing
In submitting the application to Genome BC you authorize its release under confidentiality to
any outside reviewers that Genome BC may use in its evaluation process. You also authorize
the posting of the project title and contact information on the Genome BC website. Applicants
confirm their understanding of this information sharing by signing the application form.
Meaning of the Signatures
The signatures of the project leader(s) and co-applicants attest that this Application has been
reviewed and approved for submission to Genome BC by all applicants.
The signatures of the lead investigator and authorized representative of the host organization
attest that this project has been reviewed and approved for submission to Genome BC and it is
agreed that the general conditions governing the use of Genome BC funds as outlined in the
Proof-of-Concept Program Guidelines document apply to the project outlined in this application
and are hereby accepted.
Acknowledgement of Funding
Genome BC is a not-for-profit research organization that invests primarily in large-scale
genomics based projects and supporting Innovation Centres. However, Genome BC expects to
demonstrate a return on its investment in research through benefits to BC including the
commercialization of research results. Such returns will be reinvested in genomics-based
research. Therefore, investigators must clearly acknowledge the contribution of Genome BC,
as well as all other relevant funders in all communication publications.
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CONTENTS
Page
General Instructions ..................................................................................................................... i
I.
Signature Page ................................................................................................ 1
II.
Co-Applicants .................................................................................................. 3
III.
Participating Organizations’ Signatures ........................................................... 4
IV.
Project Summary ............................................................................................. 5
V.
Market and Commercial Assessment .............................................................. 6
VI.
Project Proposal .............................................................................................. 7
VII.
Management ................................................................................................... 8
VII.
Project Team ................................................................................................... 9
IX.
Budget ............................................................................................................10
XI.
Co-Funding Strategy ......................................................................................11
Appendix I.
Budget and Supporting Documents ................................................................12
Appendix II.
Supporting Documentation for Co-Funding .....................................................13
Appendix III.
Project Team Profiles .....................................................................................14
Appendix IV.
Letters of Collaboration and Support ..............................................................15
Appendix V.
Publications ....................................................................................................16
Appendix VI.
Certification Forms .........................................................................................17
Appendix VII.
External Reviewers .........................................................................................18
Sample Gantt Chart ..................................................................................................................19
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Project title
Proof-of-Concept (POC) Program
REQUEST FOR PROJECT FUNDING
I.
SIGNATURE PAGE
Project Title:
Date of Submission:
Total Project Amount:
$ _____________
Requested from Genome BC:
Project Duration:
$ _____________
months
Project Leader(s):
Name
Affiliation
Address
Name
Affiliation
Address
Telephone
Fax
E-mail
Signature
Telephone
Fax
E-mail
Signature
1
Project title
Certification Requirements:
If this project involves performing research that requires certification, please check the relevant
boxes. If the project is accepted, the necessary certification requirements must be met in
accordance with policies on ethical conduct of research. Note that approved projects must
provide copies of certification forms prior to the flow of funds and on an ongoing basis.
Human
subjects
Human
stem cells
Animals
Biohazards
Environmental
assessment
Lead Organization: (CEO, President, VP Research, or other authorized representative)
Organization
Name of representative
Title
Date
Signature
2
Project title
II.
CO-APPLICANTS
To be completed by all co-applicants. Do not include collaborators or funding partners. These
should be listed in the appropriate sections.
A co-applicant is a researcher who makes a substantial intellectual contribution to the proposed
project and is not employed by the Lead Organization.
Name
Affiliation &
E-mail address
Signature
Date
dd/mm/yy
3
Project title
III.
PARTICIPATING ORGANIZATIONS’ SIGNATURES
This section is to be completed by organizations where co-applicants are employed and where
the co-applicants will be undertaking their work in the project.
Organization
Name & Title of Authorized
Representative
Signature
Date
dd/mm/yy
4
Project title
IV.
PROJECT SUMMARY
(Maximum 250 words)
Provide a brief summary of the project in this section, including an overview of the product or
service being developed. This section should include: a description of the proposed R&D
project, progress in research and development to date, explanation of the market opportunity
and/or competitive advantage, and details of how the proposed project will advance the existing
technology towards commercialization.
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Project title
V.
MARKET AND COMMERCIAL ASSESSMENT
(Maximum eight (8) pages including SWOT)
Provide details of the market potential and competition with respect to the product or service
being developed in the project including an assessment of the proposed product or service
compared to existing or emerging competitors. Provide a description of the competitive position
presented by the product or service including where appropriate an evaluation of the overall
intellectual property position and freedom to operate, and the strategy for commercialization
(refer to the Proof-of-Concept Program Guidelines for further details).
Provide a SWOT (Strengths, Weaknesses, Opportunities and Threats) analysis of the product
or service being developed in the project.
External Factors
Internal Factors
Sample Matrix
Positive Attributes
Strengths: identify strengths that need to
be maintained, built upon or leveraged
Negative Attributes
Weaknesses: identify weaknesses (gaps)
Examples
 Quality of locally available clinical
samples
 Standard operating protocols for
sample collection
 World class research team and
technological/methodological skills
 Intellectual Property
Opportunities: identify opportunities
Examples
 Competing product or service already
in the market place
 Access to funding in BC
 Absence of available bioinformatics
expertise
 Limited access to platform ‘a’
 Unreliable access to interview
subjects
 Lack of clinical samples
Threats: identify threats
Examples
 Advances in technology
 New international consortium in
research field ‘x’
 Emerging partnerships with industry /
policy-makers and access to samples
 Proximity to emerging markets and
industry partners to facilitate
commercialization of application
Examples
 Advances in alternative technologies /
theories
 Changing government research and
investment priorities
 Changing physician consultative
processes and adoption of new
technology
 Ability to attract key personnel
Provide details of the applicants’ plans for overcoming weaknesses and mitigating threats.
Provide details of how the applicant intends to develop and commercialize the product or
service expected to arise from this project, taking into consideration factors such as market
need, competition and commercial advantages (such as intellectual property and partnerships).
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Project title
VI.
PROJECT PROPOSAL
(Maximum eight (8) pages, plus no more than five (5) pages of supporting materials such as
references, charts, figures, tables, Gantt chart and flow diagram)
The proposal must address all relevant evaluation criteria as described in the Proof-of-Concept
Program Guidelines and typically include the following sections:
 Overall objectives and goals
 Background and preliminary data
 Detailed description of the project, including the methods and approaches
 A Gantt chart showing milestones and expected outcomes of all components of the
project, including milestones associated with further developing the commercialization of
the product or service beyond the time frame of this application (a simple Gantt chart
format is provided).
 A flow diagram of the project then integrates the various activities (e.g. science and
technology, market evaluation, intellectual property management, business
development activities) and identifies clear go/ no-go decision points including the
criteria for making these decisions. (For further information on how to prepare an
appropriate flow diagram for your proposal contact Richard Howlett at
[email protected])
 Requirement for use of any of the Genome BC Innovation Centres (A Statement of
Work for services from the Innovation Centre administration is required, which should
contain a description of the service(s) to be provided, unit costs, number of units
required, personnel requirements, data analysis requirements, etc.)
Format for references: The reference section should contain all works referred to in the text and only
those. List for each reference, in this order: name of the author(s)/editor, title, journal name or book title,
publisher, year of publication, volume, and page numbers. Journal and book titles must be given in full
and must be underlined or printed in italics. For example: Smith, A.B., Doe, J. Title of paper, Science,
2011;332:1000-1015.
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Project title
VII.
MANAGEMENT
(Maximum three (3) pages, including charts, figures, and tables)
The proposal must address the following points:
 An organizational chart showing the project’s management structure, reporting
relationships, and lines of authority (1 page maximum).
 Plans for making critical decisions about project direction, including go/no go decisions.
 Plans for handling project data (e.g., bioinformatics, statistical analysis, data protection
and data release) including a strategy for protecting know-how and intellectual property.
 To facilitate the achievement of stated project objectives, it is assumed that the applicant
will put in place either a board of external technical and/or business advisors or possibly
an external Scientific Advisory Committee, the size and composition of which will be
commensurate with the needs of the project. Provide details as to how these external
resources will be engaged to provide input, guidance and oversight to the project. Also,
provide a list of any current external advisors and a brief description of their relevance to
the project, if applicable.
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Project title
VII.
PROJECT TEAM
Using a table format, provide the following for each member of the project team: name, position,
organization; role in project (e.g., Project Leader, Co-applicant, Collaborator, Project Manager,
etc.); time commitment; brief description of their contribution to the project, and reasons for their
inclusion.
(Note: It is requested that the Curriculum vitae or résumés of key project team members be
attached to this application.)
Sample Table
Name, Position,
Organization
Team Member 1, Head
Bioinformatics Platform,
XXX University
Team Member 2,
Associate Professor,
Dept. of XX, XX
University
Role
Project
Leader
Time
Commitment
10
hours/week
Co-applicant
2 hours/week
Description of Contribution
/Reason for Inclusion
Supervision of bioinformatics
research team. Has been head of
the bioinformatics platform since
2001.
Development of plan to realize the
economic benefits of the research.
She is the lead author on key
papers about XX.
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Project title
IX.
BUDGET
(Maximum of one (1) page, plus budget templates)
Refer to the Proof-of-Concept Program Guidelines document for details about Eligible Costs
and Co-funding.
Provide a budget request for the duration of funding using the approved budget template, which
is available on the Genome BC website (www.genomebc.ca). Attach budget and supporting
documents to Appendix I. Summarize the budget and describe the financial assumptions below.
Also describe below the budgetary control processes or mechanisms that will be put in place
(e.g., processes for authorizing purchases, payments, and budget adjustments).
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Project title
XI.
CO-FUNDING STRATEGY
(Maximum of three (3) pages)
Refer to the Proof-of-Concept Program Guidelines document for details about co-funding.
Describe the co-funding strategy. At least 75% of the co-funding must be committed to the
project by the date which Genome BC receives this Application; supporting documentation for
such funding must be included. In addition, applicants must present a well developed strategy
to secure the remainder of the co-funding, and 100% of the co-funding must be committed prior
to flow of funds from Genome BC. Note: co-funding must be applied for within 18 months of
submission of the application in order to be eligible.
In a table format, provide details of the co-funding sources. For each funding source include:
organization name, amount, type (e.g., cash, in-kind), expected receipt date, status of cofunding (received, committed (see Appendix II for explanation of relevant documentation to
support this status), awaiting response, yet to apply), and a description of how the funds will
directly support the objectives of the Genome BC project. Documentation supporting the
committed or requested co-funding must be included in Appendix II.
Sample Table
#
Organization Name
Amount
Date Applied
Type
Expected
Receipt Date
Status
1
CIHR
$50,000
July 1, 2009
Cash
Jan. 2011
Received
Description of how the funds will directly support the objectives of the project:
Request to fund 2 technicians.
#
Organization Name
Amount
Date Applied
Type
Expected
Receipt Date
Status
2
Description of how the funds will directly support the objectives of the project:
#
Organization Name
Amount
Date Applied
Type
Expected
Receipt Date
Status
3
Description of how the funds will directly support the objectives of the project:
*‘Received’ is defined as cash in the bank or an in-kind contribution realized. ‘Committed’ is
defined as a formal letter of commitment to contribute an amount or in-kind from an authorized
signatory. ‘Secured’ is defined as having received a Notice of Award.
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APPENDIX I. BUDGET AND SUPPORTING DOCUMENTS
Refer to the Proof-of-Concept Program Guidelines document for details about Eligible Costs
and Co-funding.
Attach the completed budget form, which is available on the Genome BC website
(www.genomebc.ca). Contact Genome BC staff for additional assistance in the preparation of
the budget.
Also attach here supporting documents, for example:
 Letters of support and cost calculations for services provided from fee-for-service providers
 Provide a justification for out of province or out of country fee-for-service providers
 If a supporting document shows an amount that differs from the budgeted amount, you must
include the calculations used to arrive at the budgeted amount (e.g., exchange rate
calculations)
List each supporting document in the table below and reference each to the appropriate line
reference number(s) in the budget form (if applicable). The item number must appear on the
top right corner of the first page of each supporting document.
Item
#
Document Attached
Line
Reference No.
in Budget
1
2
3
4
5
6
7
8
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APPENDIX II.
SUPPORTING DOCUMENTATION FOR CO-FUNDING
Refer to the Proof-of-Concept Program Guidelines document for details about Co-funding. Note
that all co-funding must directly support the objectives of the Genome BC project and must be
applied for within 18 months of submission of the application in order to be eligible.
Attach full documentation for committed or proposed co-funding. Examples of appropriate
documentation include:
 Written confirmation (e.g., a letter or a copy of an agreement) from the co-funding source,
committing funds. This written confirmation must include: total amount of co-funding, date(s)
of expected contribution(s), and proposed use of the funds. Acknowledgement of the use of
these funds to co-fund the Genome BC project must also be included.
 For co-funding from a funding agency, foundation, or similar organization, a copy of the
application cover page, research summary, detailed budget and notice of award (if
applicable). Note that documentation must clearly demonstrate that funding is being used
for eligible costs included in the budget of the Genome BC project. The project must clearly
identify and align those budget items in the co-funding budget to the GBC budget.
 For co-funding from an industry source provide:
 For smaller and privately held companies, a copy of a Board resolution specifying the
company’s level and terms of commitment
 For larger companies, a letter from an Officer, Vice-President of Research, or
someone with similar signing authority, specifying the company’s level and terms of
commitment
 Documentation to support the financial viability of the company and its ability to fulfill
its commitment to the project (e.g., a cash flow statement, a recent audited financial
statement, etc.)
 For in-kind contributions (i.e., items that would otherwise have to be acquired with cash),
provide a clear rationale and calculation of how the value was determined (including
documentation to support all assumptions, price lists, quotes from suppliers, letters
supporting same, etc.) (see Proof-of-Concept Program Guidelines Appendix 2 for full
description of eligible in-kind contributions)
 Note that if a supporting document shows an amount that differs from the amount on the
budget form, you must include the calculations used to arrive at the budgeted amount (e.g.,
exchange rate calculations).
List the funding partner organization(s) and supporting co-funding documentation in the table
below. Link each document to the funding sources table in Section XII by grouping documents
related to each funding source and using the same number as the funding source; e.g., for
funding source 1, if there are three supporting documents, list them as 1a, 1b, 1c. The item
number must also appear on the top right corner of the first page of each supporting document.
Item
Organization
#
Document Attached
1a
Science Company Inc
Letter from President and CEO
1b
Science Company Inc
Resolution of the Board of Directors, signed
by counsel and the chairman of the board
1c
Science Company Inc
Detailed Budget
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Appendix III.
Project Team Profiles
Attach a Curriculum vitae or résumé for each key member of the project team listed in the table
below.
NAME
List in the table below the individuals for whom a
Curriculum vitae or résumé is attached
ROLE
(e.g., Project Leader, Co-applicant,
Project Manager, etc.)
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Appendix IV.
Letters of Collaboration and Support
Attach letters of collaboration and support, if applicable.
List in the tables below all collaborators and others who have provided a letter of collaboration
or support. Note that collaborators must provide a signed statement describing their
contribution to the project.
A collaborator is an individual whose role in the proposed research is to provide a special
service (such as access to equipment, provision of specific reagents, training in a specialized
technique, statistical analysis, access to populations or samples, etc.) but who is not involved in
the overall intellectual direction of the research project.
Collaborators
Name
Affiliation
Others
Name
Affiliation
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APPENDIX V.
PUBLICATIONS
Provide up to five (5) publications from the past five years, relevant to the proposal. (These do
not have to be written by the applicants but must be relevant to the content of the application).
List in the table below the documents attached.
Publications
1
2
3
4
5
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APPENDIX VI.
CERTIFICATION FORMS
Applicants proposing to perform research that requires certification, such as research involving
human subjects, human stem cells, animals, biohazards, radioactive materials, or possible
effects on the environment, must obtain the appropriate certification for the current proposed
research project. Note that certifications for similar or related projects ongoing in your
laboratory are not acceptable.
Check relevant boxes and attach certification forms.
Human subjects
Human stem cells
Animals
Biohazards
Environmental assessment
Other – Specify:
If certification forms are not yet available, indicate the expected receipt date.
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APPENDIX VII.
EXTERNAL REVIEWERS
Provide the names, contact information and expertise of five (5) potential non-Canadian
reviewers. They should not be in a conflict of interest with any of the applicants1.
Name, Affiliation
Telephone
Email
Expertise
Indicate those reviewers, if any, to whom you would prefer that your application NOT be sent.
(This could include someone with whom an investigator has had longstanding differences that
could reasonably be viewed as affecting the reviewer’s objectivity, or a direct competitor).
Name, Affiliation
Reason
1
Potential conflicts include: reviewers with whom the investigators have a financial and/or professional relationship;
the funding recommendations of the project would benefit the reviewer directly; or the reviewer feels there may be a
perception of conflict. A reviewer should not participate in the review of any proposal from a recent student, a recent
teacher, or a close personal friend. (Judgment must be applied on the basis of recentness, frequency, and strength
of the working relationship between the reviewer and the applicants.)
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SAMPLE GANTT CHART
Provide a detailed breakdown of milestones and deliverables for the two year maximum term for
the project. Thereafter list expected major milestones and deliverables for years three through
five.
Quarter Q1
ACTIVITIES
GOAL 1: Identification of
targets
a. identify genes
b. identify protein
structures
c. full protein structure
draft
0
Q2
Q3
Q4
Q5
Q6
Q7
Q8
1H
Y3
2H
Y3
1H
Y4
2H
Y4
1H
Y5
2H
Y5
0
2
2
2
GOAL 2: Translation to
end user
A
B
C
MILESTONES
RESULTS
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