Attachment F
NATIONAL SCIENCE FOUNDATION
Small Business Innovation Research (SBIR)
SBIR PHASE II PROPOSAL COVER PAGE

Phase I Award No. 
     	Topic No. 
     	SubTopic Letter (if any)
     	
Proposal Title
     
	
Company Name:
     
	Employer Identification Number (EIN) or
Taxpayer Identification Number (TIN)
     	
Address (including address of Company Headquarters and zip code plus four digit extension)
     

Requested Amount
$      	Proposed Duration
     	Period of Performance
     	
THE SMALL BUSINESS CONCERN CERTIFIES THAT:	Y/N	
1.  It is a small business as difined Section 2.12.	     	
2.  It qualifies as a socially and economically disadvantaged business as defined Section 2.14. (FOR
STATISTICAL PURPOSES ONLY)	     	
3.  It qualifies as a women-owned business as defined in Section 2.17. (FOR STATISTICAL PURPOSES ONLY)	     	
4.  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 defined in Section 3.1.12	     	
5.  A minimum of one-half of the research will be performed by this firm in Phase II.	     	
6.  The primary employment of the Principal Investigator will be with this firm at the tiime of award and
during the conduct of the research.	     	
7.  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 that may be interested in further information or possible investment.	     	
8.  It will comply with the provisions of the Civil Rights Act of 1964 (P.L. 88-352) and the regulations pursuant thereto.	     	
PRINCIPAL INVESTIGATOR /PROFECT DIRECTOR	
Name
     	Title
     	
Social Security No.
     	Telephone Number
     	
E-Mail Address
     	Fax Number
     	
COMPANY OFFICER (FOR BUSINESS AND FINANCIAL MATTERS)	
Name
     	Title
     	Telephone Number
     	
OTHER INFORMATION	
President’s Name

     	Year Firm 
Founded
     	Number of Employees
Average Previous 12 Mo.:      
Currently:      	
PROPRIETARY NOTICE: See Section 5.5 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 12O7-PII (SBIR) (2/97)				Proposal Page No. 1        

Attachment F
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 test and graphics herein are as well as any accompanying publications or other documents, unless
  otherwise indicated, are the original work of the signatories or individuals working under their supervision.
  I agree  to accept responsibility for the scientific conduct of the project and to provide the required progress.
I understand that the willful provision of false information of 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, drug free workplace, and lobbying activities (see below), as set forth in the Grant Policy Manual, (GPG), NSF 98-2. 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?

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

 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 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  or 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 Company Officer	Signature	Date	
Name/Title (Typed)
     		     	
Telephone Number
(   )    -    	Electronic Mail Address
     	Fax Number
(   )    -