中国南宁海(境)外人才创新创业大赛 南宁市海外高层次人才与项目对接会

附件4 2019年第二届南宁市海(境)外人才 创新创业大赛报名表Application Form for 2019 Nanning International Elite Innovation and Entrepreneurship Competition

2019年第二届南宁市海(境)外人才

创新创业大赛报名表

Application Form for 2019 Nanning International Elite

Innovation and Entrepreneurship Competition

 

填表须知/Instructions

优先使用中文填写报名表,无法使用中文的请使用英文填写;表中★为必填信息

Please fill in the application form in Chinese or English (please use Chinese if possible); “★” mark in the form means mandatory information.

参赛主体拥有参赛项目全部知识产权且无产权纠纷,参赛主体拥有参赛项目部分知识产权的,应提供其他所有权人授权参赛证明,如引发知识产权纠纷概与南宁市海(境)外人才创新创业大赛无关。

The participants should own all of the intellectual property rights of the project and has no related disputes. The participant who has only a part of the intellectual property right shall submit the authorization to participate in the competition by other co-owners. 2019 Nanning International Elite Innovation and Entrepreneurship Competition is not responsible for any intellectual property disputes caused by the application materials.

3.参赛主体知悉并同意将其提交的项目资料提供给大赛组委会、评委、南宁市有关部门等大赛相关方面,参赛主体应对其项目重大技术秘密等做好保密处理,因参赛主体处理不当导致技术泄露的,南宁市海(境)外人才创新创业大赛组委会不对此负责任。

Participants understand and agree to submit relevant project materials to the organizing committees, judges and government agencies in Nanning. The applicants are responsible for the confidentiality of the materials submitted. The organizing committee of the competition will not be held liable for any technology leaks caused by the applicant’s improper handling.

4.参赛主体已知悉并同意以上条款。

All participants should understand and consent to the above-mentioned articlesbefore proceeding with filling in the form.

★参赛项目/Project  中文名称/Chinese name
 英文名称/English name
所属领域/Industrial field □电子信息技术/Electronic Information

□先进装备制造/Advanced Equipment Manufacturing

□生物医药/ Biology and/or Pharmaceuticals

□新材料/New Material

□新能源、节能环保技术/New Energy, Energy-conservation and Environmental Protection

□医疗器械/ Medical Apparatus and Instruments

□现代农业/Modern Agriculture

□科技金融/ Science &Technology and Finance

□其它,请注明/If others, please specify:                 

是否曾获南宁市本级财政资助或南宁市本级组织的创新创业大赛奖励Whether the project submitted has received Nanning government’s fund or the award of innovation competition in Nanning □是/Yes(请填写受资助项目名称及年份/Please specify project name and year

                                          

□否No

参赛主体/Participants ★类别/Category of Participants □企业/Registered Enterprise  □团队/Group

□个人/Individual  □高校Higher Education Institution

□科研机构/R&D institution

★名称(如获奖将作为授奖对象) Name (also used in the award certificate)
★ 是否有违反中国法律/Records of violations of Chinese laws □是/Yes

□否/No

★ 是否有不良信用记录/Records of bad credit □是/Yes

□否/No

★是否拥有参赛项目全部知识产权且无产权纠纷/ Full ownership of the intellectual property right and no related disputes □是/Yes

□否/No

参赛主体拥有参赛项目部分知识产权的,是否提供其他所有权人授权参赛证明Participant who has only a part of the intellectual property right shall submit the authorization to participate in the competition by other co-owners □是/Yes

□否/No

★项目组核心成员(表格不够可自行添加)

Major members of the team (please add columns if there is not enough space)

姓名(中/英文)

Name (Chinese/English)

国籍Nationality 职务Position 海(境)外经历国家/区及时间段 Time period of the stay in overseas countries & regions (Hong Kong, Macao, Taiwan)
★ 项目负责人基本情况/Basic information of the project manager 姓名(中/英文)Name (Chinese/English) 出生年月/ Birth (Year-

Month)

性别/Gender
身份证或护照号码

/ID or passport number

现居住国及城市/Current residence country & city
联系电话/Contact number 电子邮箱/Email
接受高等教育机构及专业

Name of the university/college and major

国别Country 取得学位Degree
学士学位Bachelor degree
硕士学位Master degree
博士学位Doctorate degree
现任职机构

/Current affiliation

职务(职称)/Title
★ 项目负责人基本情况/Basic information of the project manager 主要学习、工作经历和成就/Education background, work experience and achievements (500字以内/no more than 500 words)
拥有海(境)外经历核心成员基本情况/Basic information of the main member who has overseas background(项目负责人无海境外经历的项目填写)(for those whose project manager has no overseas background) 姓名(中/英文)Name (Chinese/English) 出生年月/Birth Year-Month 性别/Gender
身份证或护照号码

/ID or passport number

现居住国及城市/ Current residence country & city
联系电话/Contact number 电子邮箱/Email
接受高等教育机构及专业Name of the university/college and major 国别Country 取得学位Degree
学士学位Bachelor degree
硕士学位Master degree
博士学位Doctorate degree
现任职机构

/Current affiliation

职务(职称)/Title
拥有海(境)外经历核心成员基本情况/Basic information of the main member who has overseas background(项目负责人无海境外经历的项目填写)(for those whose project manager has no overseas background) 主要学习、工作经历和成就/ Education background, work experience and achievements (500字以内/no more than 500 words)

 

★ 其他参赛主体及项目核心成员学习、工作经历和成就介绍(可附页)/Introduction of education background, work experience and achievements of other main members of the participating team

 

 

 

 

 

 

 

 

 

 

 

 

 

 

★ 项目摘要/Project description:(1000字以内,说明项目特点、用途,技术指标、技术成熟度、产业化前景、个人贡献及团队经验、金融分析等/Please use a maximum of 1000 words to specify the characteristics, purpose, technical indicators, technical maturity, industrial prospects, personal contribution and team experience, financial analysis, etc..)

 

★知识产权/

(可附页)Intellectual property right (New pages can be attached if there is not enough space)

类别(专利/药品批件/软件著作权/品种审定证书/其他请注明)

Category (patent/drug production approval number/software copyright/ varieties examination and approval certificate/if others, please specify)

注册国家Country where it is registered 登记编号File number 状态(授权/受理中)Status (

authorized/pending)

所有权人Owner
★ 项目落地方式

Project launch format

自主创业/Self-funded 投资总额/Total investment:          万元/Ten thousand RMB
项目合作/Project collaboration

 

□ 融资创业/Seek funding

□ 技术合作开发/Seek technology collaboration

□ 以技术入股/ Technology as a form of capital contribution

□ 技术转让或实施许可/Technology transfer or exploitation

□ 学术/科研交流/Academic and research

□ 其他(请说明)/Others to specify

财务数据

Financial data

2018 2019(预期)2019 estimated 2020(预期)2020 estimated 2021(预期)2021 estimated
营业收入(万元人民币)

Revenue (   ten thousand RMB)

融资需求(万元人民币)

Fund that needs to be financed (    ten thousand RMB)