Project Title
Principal Investigator (PI)
PI Research Institution or Company Name
Address
Contact E-mail and Phone Number
Proposed Total Project Budget (including cost share)
Total Cost Share Requirement
Amount Requested from MassCEC[1]
Technology Category
(check all that apply) / Energy efficiency
Demand response
Energy conservation
Solar power
Wind power
Geothermal
Wave and tidal energy
Advanced hydropower
Energy storage
Biofuels
Renewable, biodegradable chemicals
Advanced thermal-to-energy conversion
Hydrogen / Fuel cells
Carbon capture/sequestration
Energy monitoring
Green building materials
Energy-efficient lighting
Gasification and conversion to liquid fuels
Demand-side management
Combined heat and power
Other technology powered by the sun, wind, water, biomass, alcohol, wood, fuel cells, or any renewable, non-depletable or recyclable fuel
Other
[insert description here]
Note that coal, oil, natural gas (except when used in fuel cells or combined heat and power), and nuclear power are not eligible for AmplifyMass awards.
For Company Applicants Only
Number of Full-Time Equivalent Employees
Sources and Amount of Funding to Date
Revenue History (by year)
Location(s) of all company operations.
Are you applying for professional grant writing assistance?[2] / Yes
No
If yes: provide the name & contact information for the consultant you plan to hire.
Technology Overview (200 words or less)
· Description of the technology and its stage of development
· Application(s) and problem(s) it solves
· Description of the intellectual property, if applicable
Commercialization Potential (200 words or less)
· Target market(s) for the technology, market size(s), and growth trajectory
· Proposed business model
· Go-to-market strategy
Information on ARPA-E Partner Research Institutions or Companies (if applicable)
· Names, brief descriptions, and locations of each Partner
· Project role of each Partner
· Breakdown of project budget allocated to each Partner
Required Attachments
ÿ ARPA-E Concept Paper
ÿ ARPA-E Response to Concept Paper
ÿ Resumes of team members
ÿ Authorized Applicant’s Signature and Acceptance Statement (attached below)
ÿ Notice of Confidential Information Cover Letter[3]
Applications should be submitted via e-mail to with the subject line “AmplifyMass Pre-Qualification Application – [Research Institution or Company Name].”
QUESTIONS?
MassCEC AmplifyMass Awards
Program Manager: Alison Ernst
Massachusetts Clean Energy Center
63 Franklin Street, 3rd Floor, Boston, MA 02110
Phone: 617-315-9389 Email:
AmplifyMass
Authorized Applicant’s Signature and Acceptance Statement
The undersigned is a duly authorized representative of the Applicant listed below. The Applicant has read and understands the Program requirements as outlined in the AmplifyMass Solicitation for Applications (the “Solicitation”). The Applicant acknowledges that all of the terms and conditions of the Solicitation are mandatory.
The Applicant specifically acknowledges the application of the procedures regarding submission of sensitive information as set forth in the Solicitation, and specifically agrees that it shall be bound by those procedures. The Applicant understands that all materials submitted as part of this Pre-Qualification Application (the “Application”) are subject to disclosure under the Massachusetts Public Records Law, codified at Chapter 66 of the Massachusetts General Laws, unless exempt from public disclosure under a statutory or common law exemption, including the limited exemption at Massachusetts General Laws Chapter 23J, Section 2(k) regarding confidential information submitted to MassCEC by an applicant for any form of assistance.
Applicant acknowledges and agrees that MassCEC has no obligation, and retains the sole discretion to fund or choose not to fund the Application set forth herein, and that MassCEC’s receipt of the Application does not imply any promise of funding at any time.
I certify that the statements made in this Application, including all attachments and exhibits, are true and correct to the best of my knowledge.
AUTHORIZED SIGNATORY: ______
Print Name: ______
Title: ______
Date: ______
[PI Last Name] Date of Application: [MM-DD-YYYY]
[1] If a university applicant, this amount may not exceed $100,000. If a company applicant, this amount may not exceed $300,000.
[2] MassCEC will fund 50% of professional grant writing expenses, up to $5,000, to assist with submission of a full ARPA-E application. Awards are reimbursable and will be made on a first come, first served basis, subject to limited availability.
[3] Only include if any confidential information has been submitted with this application.