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APPENDIX B

NATIONAL SCIENCE FOUNDATION
Program Solicitation: NSF 98-153
Closing Date: December  14, 1998

STTR PHASE I -- PROPOSAL COVER PAGE

TOPIC

EMPLOYER IDENTIFICATION NUMBER (EIN) OR TAXPAYER IDENTIFICATION NUMBER (TIN)
PROPOSAL TITLE
NAME OF COMPANY
 		 NAME OF RESEARCH INSTITUTION
 
ADDRESS (including  zip code)

 

 RESEARCH INSTITUTION ADDRESS (including  zip code)

 
REQUESTED AMOUNT

$

 PROPOSED DURATION

12 months

 PERIOD OF PERFORMANCE
THE SMALL BUSINESS CERTIFIES THAT:  Y/N
1. It is a small business as defined in the STTR  solicitation  
2. It qualifies as a socially and economically disadvantaged business as defined in the STTR solicitation. FOR STATISTICAL PURPOSES ONLY.  
3. It qualifies as a woman-owned business as defined in this solicitation. FOR STATISTICAL PURPOSES ONLY.  
4. It will exercise management direction and control of the performance of the STTR funding agreement.  
5. NSF is the only Federal agency that has received this proposal (or an overlapping or equivalent proposal) from the small business concern. If No, you must disclose overlapping or equivalent proposals and awards as required by the STTR solicitation.  
6. It will perform _____percent of the work and the collaborating research institution will perform _____percent of the work as described in the proposal.  
7. The primary employment of the principal investigator will be with this firm at the time of award and during the conduct of the research.  
8. It will permit the government to disclose the title and technical abstract page, plus the name, address and telephone number of a corporate official if the proposal does not result in an award to parties who may be interested in contacting you for further information or possible investment.  
9. It will comply with the provisions of the Civil Rights Act of 1964 ( P. L. 88-352) and the regulations pursuant thereto.  

 PRINCIPAL INVESIGATOR / PROJECT DIRECTOR
 NAME
  TITLE
 SOCIAL SECURITY NO.  HIGHEST DEGREE / YEAR  E-MAIL ADDRESS
 TELEPHONE NO.  FAX NO.  WEB ADDRESS

 RESEARCH INSTITUTION INVESTIGATOR)
 NAME
  SOCIAL SECURITY NO.  TELEPHONE NO.

 COMPANY OFFICER (FOR BUSINESS AND FINANCIAL MATTERS)
 PRESIDENT'S NAME  YEAR FIRM FOUNDED NUMBER OF EMPLOYEES
AVERAGE PREVIOUS 12 MO.:
CURRENTLY:

PROPRIETARY NOTICE: See Section 7.5 for instructions concerning proprietary information.
(Check Here if proposal contains proprietary information.)

NOTE: The signed Certification Page MUST be included immediately following this Cover Page with the original copy of the proposal only.

NSF FORM 1207 (SBIR 12/96)

 

CERTIFICATION PAGE

Certification for Principal Investigators
I certify to the best of my knowledge that:

(1) the statements herein (excluding scientific hypotheses and scientific opinions) are true and complete, and
(2) the text and graphics herein are as well as any accompanying publications or other documents, unless otherwise indicated, are the original work of the signaatories or individuals working under their supervision. I agree to accept responsibility for the scientific conduct of the project and to provide the required progress reports if an award is made as a result of this application.

I understand that the willful provision of false information or concealing a material fact in this proposal or any other communication submitted to NSF is a criminal offense (U.S. Code, Title 18, Section 1001).

 Name (Typed)  Signature  Date
 PI/PD    

Certification for Authorized Organizational Representative or Individual Applicant
By signing and submitting this proposal, the individual applicant or the authorized official of the applicant institution is: (1) certifying that statements made herein are true and complete to the best of his/her knowledge; and (2) agreeing to accept the obligation to comply with NSF award terms and conditions if an award is made as a result of this application. Further, the applicant is hereby providing certification regarding Federal debt status, debarment and suspension, drugfree workplace, and lobbying activities (see below), as set forth in the Grant Proposal Guide (GPG), NSF 95-27. Willful provision of false information in this application and its supporting documents or in reports required under an ensuring award is a criminal offense (U.S. Code, Title 18, Section 1001).

In addition, if the applicant institution employs more than fifty persons, the authorized official of the applicant institution is certifying that the institution has implemented a written and enforced conflict of interest policy that is consistent with the provisions of Grant Policy Manual Section 510; that to the best of his/her knowledge, all financial disclosures required by that conflict of interest policy have been made; and that all identified conflicts of interest will have conflict of interest policy. Conflicts which cannot be satisfactorily managed, reduced or eliminated must be disclosed to NSF.

Debt and Debarment Certifications (If answer "yes" to either, please provide explanation.)

Is organization delinquent on any Federal debt?  YES  NO
Is the organization or its principals presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a Federal Department or agency?
 YES  NO

Certification Regarding Lobbying
This certification is required for an award of a Federal contract, grant or cooperative agreement exceeding $100,000 and for an award of a Federal loan or a commitment providing for the United States to insure or guarantee a loan exceeding $150,000.

Certification for Contracts, Grants, Loans and Cooperative Agreements
The undersigned certifies, to the best of his or her knowledge and belief, that:

(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer of employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with the awarding of any federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal Contract, grant, loan, or cooperative agreement.

(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, and officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure of Lobbying Activities," in accordance with its instructions.

(3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements and that all subrecipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

 Authorized Organizational Representative  Signature  Date
Name /Title (Typed) 

    
Telephone Number

  Electronic Mail Address  Fax Number