(Entrepreneurship Development Center) / Registered office :100, NCL Innovation Park
Dr. Homi Bhabha Road
Pune- 411008, India
Phone: +91-20-25865877/ 64011026
Fax:+91-20-25865879
Web: www.venturecenter.co.in
Email:

Application Form: Hot Lab Services

(Revised: 30 August, 2017)

VC/HLS/2017-18/ Date:

1. Applicant information
1.1 / Applicant full name
1.2 / Name of company
1.3 / GST Registration No. / GST Registration State
1.4 / Affiliation/ profession
1.5 / Full postal address for correspondence
1.6 / Phone
1.7 / Email
2. Application for discounts
2.1 / I wish to apply for the following discounts:
Residents of dedicated lab spaces at Venture Center
Incubatees of Venture Center's Lab2Mkt program and Proof-of-concept projects associated with Venture Center
CSIR-NCL scientists and students; Start-ups with substantial NCL related participation (know-how, staff, students, alumni)/ VC related participation (alumni)
Not-for-profit companies, Educational and research institutes; Social enterprises
2.2 / Please attach any attachments to support your claim for discounts (if required)
3. Application for services
Service type / Number of people / Number of Days/ Months
HLS01 / Hot Lab service
HLS02 / Workspace with Storage
HLS03 / Facility operated Hot Lab service / Name of Instrument / Number of Hours
HLS04 / Minus 80 degree storage / Number of sliding trays / Number of Months
HLS05 / Minus 20 degree storage / Number of racks / Number of Months
HLS06 / 4 degree storage / Number of shelves / Number of Months
HLS07 / Liquid nitrogen storage / Number of boxes / Number of Months
Number of Liters
HLS08 / Ultrapure Type I water
HLS09 / Type II water
Discounts applicable on service type HLS01, HLS02 and HLS03 only

IMPORTANT:

Filling of EHS Information Request Form is mandatory ONLY if user is planning to bring any hazardous chemicals (list available with Venture Center) or biologicals (needing Bio Safety level 2 or above) in Hot Labs.

Payment Terms:

o  All services are offered against advance payment in full. Service tax and other taxes applicable at the prevailing rate shall in addition to the above.

o  Payment via a) Demand Draft, b) Cheque payable in Pune or at par or c) bank transfer are possible. All payments have to be made in the name of “Entrepreneurship Development Center”

o  Booking once made shall not be transferrable or payment made thereof shall be non-refundable. On the occasional case where Venture Center is unable to carry out the experiment due to equipment failure or contamination or absence of staff, Venture Center shall inform the applicant immediately and refund the payments made to it.

It is hereby declared that the undersigned has read and understood the terms and conditions of Venture Center’s Hot Lab service and accepts the same.

The undersigned authorized representative of the applicant also declares that all the information given herein above is true and correct to the best of his personal knowledge and belief and also understands that in the event of any information found to be untrue or incorrect, the contract of the said services is liable to be terminated forthwith.

For and on Behalf of
For Office Use Only / (Name of the Company)
Total charges (Rs.)
@ pricing / (Name of the authorized signatory)
Discount @
Net Charges (Rs.) / Designation
Taxes if applicable

EHS Information Request

To be filled in by the users ONLY if planning to bring any hazardous chemicals (list available with Venture Center) or biologicals (needing Bio Safety Level 2 or above) in Hot Labs.

Hazardous chemicals
1 / Brief description of the chemical
2 / Are following procedures in place? / Yes / No
3 / MSDS is available
4 / Users thoroughly familiar with the information contained in the MSDS of the chemicals
5 / Appropriate personal protective equipments are available
6 / Standard operating procedures (SOPs) incorporating other safety interventions to ensure the safest possible conduct of the work
7 / Storage & waste disposal protocol is available
8 / Emergency protocol is available
Hazardous biological materials
1 / Brief description of the biological material
2 / Are following procedures in place? / Yes / No
3 / Risk assessment
4 / Assigned biosafety level to the planned work
5 / Appropriate personal protective equipments are available
6 / Standard operating procedures (SOPs) incorporating other safety interventions to ensure the safest possible conduct of the work
7 / Storage & waste disposal protocol available
8 / Emergency protocol available

It is hereby declared that the undersigned has read and understood the terms and conditions of Venture Center’s Hot Lab services and accepts the same.

The undersigned authorized representative of the applicant also declares that all the information given herein above is true and correct to the best of his personal knowledge and belief and also understands that in the event of any information found to be untrue or incorrect, the contract of the said services is liable to be terminated forthwith.

Name of the authorized signatory

For and on Behalf of

(Name of the Company)

Designation

The Entrepreneurship Development Center (service mark: Venture Center) is incorporated under Section 25 of the Companies Act, 1956 (India). Venture Center is a member of the Indian STEP and Business Incubator Association (ISBA) and the National Business Incubation Association (NBIA). CIN-U73100PN2007NPL129455