Please indicate your interest by completing and submitting this form as indicated below. If you are expressing interest as an individual - e.g. independent consultant/student - please tick here and complete the sections from 1.3.1 onwards.

1 Company details 1.1 Sector ACAD () PARA () INDIV () AM&M () GOV () ELEC () SERV () BIOS () () AM&D () FIN () PROF () ICT () Information & Communications Techn (ICT) Financial/Investment Entities (FIN) Professional Services (PROF) Aerospace, Maritime (AM&D) Unknown (UNK) Electronics (ELEC) Service Providers/Suppliers (SERV) Government (GOV) Advanced Manufac, & Mat (AM&M) Individuals (INDIV) Media (MEDIA) Parastatals incld. Science Cncls (PARA) Academic: Tertiary Instits (ACAD) 1.2 Registered Company Name 1.2.1 Registration No 1.2.2 Website [if applicable] 1.2.3 Trading as [if applicable] 1.2.4 Business Location Local National - listed International Individual Individuals please complete this next section 1.3.1 Physical Address Address 1 Address 2 Postal Code Town/City Province Country 1.3.2 Postal Address Address 1 Address 2 Postal Code Town/City Province 2 Contact Details Contact Person Title [Mr/Ms/Mrs/Dr/Prof/Other] First Name Surname Designation AdministratorAdministrative AssistantsVice President of SalesAnalystDoctorChairmanDirectorConsultantDistrict ManagerEngineerExecutive Vice PresidentManagerMarketing ManagerOffice ManagerOwnerPartnerPresidentPurchasing ManagerRegional ManagerSales ManagerSales RepresentativeSecretarySupervisor Profession Department [in relation to above company if applicable] Direct e-mail address Direct Tel No & Code Direct Fax No & Code Mobile Phone 3 Interest I am/Our company is interested in... 3.1 Tenancy Yes  No  Type Freehold Lease 3.1.1 Space Requirements   m2 3.1.2 IT Requirements 3.1.3 Other Requirements 3.2 Offerings of The Innovation Hub 3.2.1 Pre-Incubation 3.2.2 Incubation 3.2.3 CoachLab™ Yes  No  As a graduate student As a sponsor/ partner company 3.2.4 Hub Anchor projects Teleport The Switch 3.3 Being a Service Supplier 3.3.1 On Site    Off Site   Segment Unknown Banking Incubation Legal Air Force Infrastructure Marketing Telecomms Travel Organisational Development Provincial Science Parks Venture Capitalist Beneficiation Grants Industry ICT Automotive Research Office Supplies Design Organisational Developlemt Property Management Restaurant National Catering Supplies Chemical Local Materials IT : Hardware Print Science Council IT: Hardware Intellectual Property Business Development Electronic : TV Economics University Electronic : Web Foreign Human Resources Photography Technikon IT Land Owner IT : Software Insurance Security Agency Furniture System Integrators Temps Exhibition Accounting Incubator Print : Daily Print : Weekly Print :Weekly Trust Property Developers PR & Comms Systems Designers Architects Management Paper College Environmental Mangement Cleaners Property IT : Web Event Production Other Sector: Describe type of Sector Space required (m2) Other requirements 3.4 Investment Opportunities 4 Follow-up needs 4.1 Exploratory Meeting At your business address At The Innovation Hub Management Company (Pty) Ltd 4.2 Presentation on The Innovation Hub At your business address At The Innovation Hub Management Company (Pty) Ltd 4.3 Visit To The Innovation Hub site 5 Keep me informed Please add me to the mailing list for The Innovation Hub's NewsBits (e-news on specific activities) Innov8 (Community Networking Newsletter) Annual Report Prospectus