CONFIDENTIAL

Innovation to Protect (I2P) Grant Grant Extension Form

(Without change in total grant amount)

Submission Details

ALL sections of this form must be completed.

This form must be endorsed by the I2P Grant Applicant and the Applicant’s respective host institution’s Research Director or his/her designated authority.

This form must be submitted through the below designated offices from respective healthcare clusters:

Healthcare Cluster Designated Office

Alexandra Health System KTPH Clinical Research UnitEastern Health Alliance EHA Centre for Innovation

Jurong Health Jurong Health Research OfficeNational Healthcare Group NHG Research & Development Office

NUHS NUHS Research OfficeSingHealth SingHealth Office of Intellectual Property (SHIP)

Only forms with following two (2) submissions received by the I2P Grant Secretariat will be accepted:

A. One softcopy submission containing the following documents to be emailed to I2P Grant Secretariat at ip@nhic.sg with the subject header “(NHIC I2P Reference Number)_(Grant Extension Form)”.

I2P Grant Extension Form [NHIC-I2P-7] (One word format without signatures and one PDF format with signatures)

PDF format of additional attachments (if necessary)

B. One hardcopy submission, with signatures, to be sent and received three (3) working days later from the date of softcopy submission, to the following address:

Attn: I2P Grant Secretariat; National Health Innovation Centre61 Biopolis Drive #01-02 Proteos; Singapore 138673

________________________________________________________________________________

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Important: All information disclosed in this form is treated with confidence. The information is furnished to NHIC with the understanding that it shall be used or disclosed for evaluation, reference and reporting purposes.

CONFIDENTIAL1. I2P Grant Details

NHIC Reference Number

Title of Invention

Applicant Details

(Name, Designation, Institution, Telephone & Email address)

Grant Commencement Date

DD/MM/YYYY_______________________

Grant Expiry Date

DD/MM/YYYY _______________________

Budget Information OOE

Grant approved $

Expenditure to date $

Balance $

Remarks (if any)

2. Grant Extension Requested

From: To:

Length of requested extension: months (Maximum six months)

Total approved extension to date: months

3. Reason for Extension

(Please explain why the extension is required and impact on funded patent application; Use a separate attachment if needed)

________________________________________________________________________________

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dd/mm/yy dd/mm/yy

CONFIDENTIAL

4. Declaration by the Applicant

I hereby declare that all the information provided by me in this form is accurate and true to the best of my knowledge and that I would be responsible for the consequences of providing false and/or misleading information.

____________________________Signature of Applicant

Name:

Date:

Endorsed by:

____________________________________________________Signature of Research Director or His/Her Designated Authority

Name:

Date:

________________________________________________________________________________

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