Application form
(Individual Company)
This is an application form to apply for Grants under the Palestinian Market Development Program. It contains three sections:
(A) Company Profile
(B) Project Plan
(C) Self-Declaration
For more clarification on how to fill this form, please see attached Application Instructions.
Or you are welcome to contact us via or by phone.
(A) Company ProfileA-1: General info
Company Name:
Sector / Industry /
/
Head office address
City / Town:
Governorate
Telephone:
Fax:
E-Mail Address:
Website:
Factory /Office location (s)
If your company/factory or any of its branches in following marginalized areas? For areas definition, please see the instructions attached /
A-2: Contact Person
Name:
Title:
Address:
Cell Phone:
E-Mail Address:
A-3: Legal
Year Established:
Legal Type: /
/
Authorized Dealer Number:
Note: Please attach copy of company registration certificate
A-4: Owners of the company: “if Board , please list up to 5 main shareholders”Full Name / Gender
Male/Female / Title / I.D no. / Age / Date of Birth / Cell Phone
A-5: Top Management
Full Name / Gender
Male/Female / Title / I.D no. / Age / Date of Birth / Cell Phone
Note: Please attach a copy of the Owners (Board if applicable), General Manager and Financial Manager IDs.
A-6: MembershipPlease provide information about membership in the following in following institutions including Membership Year and Membership Status:
Chamber of Commerce: / Organization Name:
Membership Year:
Membership Status:
Trade or Industrial Association: / Organization Name:
Membership Year:
Membership Status:
Other, Specify: / Organization Name:
Membership Year:
Membership Status:
A-7: Markets
Current Local and International markets served: / Local:
/ Export, Specify:
For more info about the classification of markets, please refer to Application instructions
A-8: Consultants
Have you ever used a Business Service provider/consultant? /
If yes, How did you paid for it? /
A-9: Pervious Donors Assistance
Have you ever received Previous donor assistance? /
(If YES, please answer the following questions)
Have you ever received a grant from Facility for New Market Development (FNMD) project before? /
Have you received a grant or currently implementing a grant from PMDP project before? /
If the donor is other than PMDP and FNMD, please specify: Donor(s) Name, amount, period of duration and project that has been funded?
A-10: Financial Performance of Company
Balance Sheet Data:
Years / 2012 / 2013 / 2014 / Projected 2015
Total Assets ($)
Total Liabilities ($)
Equity($)
Income Statement Data:
Local (Sales) ($) includes East Jerusalem but does not include Israel)
Sales to Israel ($)
Sales to other countries($)
Total Sales
Expenses (Cost) ($)
Net Profit (Net income/Loss) ($)
Total # of Employees: / 2012 / 2013 / 2014 / Projected 2015
Males (Full time)
Males (Part time)
Females (Full time)
Females (Part time)
For part time employees:
How many hours per week do they work – on average?
(B) Project Plan
B-1: Project Plan Summary:
Please describe you project plan according to table below:
Product[name goods/services and give a brief description] / Product (i.e. goods/services) status / In which markets are the product already sold?
[cities/countries] / Where would you like to sell the product?
[target cities/target countries]
A /
/ Local:
/ Export, Specify: / Local:
/ Export, Specify:
B /
/ Local:
/ Export, Specify: / Local:
/ Export, Specify:
C /
/ Local:
/ Export, Specify: / Local:
/ Export, Specify:
D /
/ Local:
/ Export, Specify: / Local:
/ Export, Specify:
B-2: Project Plan description:
Please describe your current/new/ improved product(s).
Describe potential clients in the target markets(s).
What is your competitive advantage in the target market(s)?
B-3: PMDP Additionality
What will happen to your proposed plan if PMDP does not provide grant support?
Please select one of the followings:
B-4: Strategy and Plan to achieve objectives:
What are the steps required to achieve your project’s objectives? What steps you lack?
B-5: Breakdown of activities
Please provide breakdown of large expense items
No. / Description of activities / Estimated cost (USD $) / Starting date of implementation / Ending date of implementation
Total
Once you complete this form and signed the following page “Self-Declaration”, please send it to or send hard copy to PMDP office.
Ramallah office:
4th floor, Millennium Bldg., Kamal Naser St., Al Masayef Tel: +970 2 2986340, Fax: +970 2 2959220
Gaza office:
6th floor, Al-Thefer 9 Bldg, Qanal St., Al Remal Tel: +970 8 2825888, Fax: +970 8 2825889
(C) Self-Declaration
We hereby (Company name: ) declare that we:
Are committed to contributing our share of the project costs
Has sufficient resource [access to liquid assets] to pay BSP fees or other project expenses
Are not bankrupt or being wound up;
Are not having our affairs administered by the courts;
Have not entered into an arrangement with creditors regarding the proposed project in the application;
Have not suspended business activities;
Have not been guilty of grave professional misconduct;
Have not been the subject of a judgment for fraud, corruption, bribery, involvement in a criminal organization or any other illegal activity detrimental to the PMDP' project;
Have fulfilled obligations relating to the payment of social security contributions and the payment of taxes in accordance with the legal provisions of the country in which we are established or with those of the country of the Contracting Authority or those of the country where the contract is to be performed;
Are in compliance with national environmental regulations and requirements;
Have no potential conflict of interests or any equivalent relation in that respect with other Candidates or other parties in the pre-qualification process at the time of the submission of this application; and
Will inform the PMDP immediately if there is any change in the above circumstances at any stage during our engagement with the PMDP.
Confirm that all information provided in this application form is correct and accurate
Inform PMDP promptly of any changes in its officers, name, legal status, address, or telephone/fax number.
"The PMDP management reserves the right to examine and approve every applicant and application submitted to it in accordance with the project's current procedures. By submitting your application you accept to be subject to the project's procedures for such examinations and to whatever decision the project management takes on whether to accept or reject your application. The project management and project donors are under no obligation to divulge the reasons for rejecting your application should the project management decide to do so. You also undertake that you will not hold the project management or the project donors responsible for any consequences howsoever arising from the rejection of your application should such rejection occur."
Signature of authorized representative
______
Name and position of authorized representative
______
Company’s official Stamp:
Date:
Application Instructions
Purpose
The Grant Application Form serves as a first screening step for potential grant activities. The form is designed to gather essential basic information about the Applicant and what it is proposing to do.
Instructions by Section
Section A: Company Profile
This section is to describe the current situation of the company and is divided into the following sections:
Item A-1: General Info - Company’s name, sector, address, telephone, and fax—self-explanatory
Item A-2: Key contact person & title—The contact person is responsible for communications between PMDP and the Applicant. This applies to all aspects of the grant, from the initial summary through completion. The contact person must have full authority and responsibility to act on behalf of the Applicant. The contact person should be someone who will be directly involved with the grant activity and has a proven, established relationship with the Applicant.
Margilized areas are:
Area C / The areas that are located in West Bank and are fully controlled by IsraelJordan Valley / All Area located in Jordan Valley
Seam Area / Tulkarm
Barta'a Sharqiya
Umm ar-Rihan
Khirbet 'Abdallah al-Yunis
Khirbet Ash-Sheikh Sa'eed
Khirbet al-Muntar al-Gharbiya
Khirbet al-Muntar ash-Sharqiyya
Dhaher al-Malik
Jerusalem
Bir Nabala
Beit Hanina (West Bank side)
Al-Judeira
Al-Jib
Bethlehem
Battir
Husan
Nahalin
Wadi Fukin
Al Jab'a
Khirbit Zakariyya
Khirbit Al Ballouta
Khallet 'Afana
Al-Walaja
Qalqilya
Azzoun
Ras Tira
Dab'a
Wad Rasha
Arab a-Ramadeen
Hableh
Ras Atiya
Izbat Jalud
East Jerusalem / The areas of Jerusalem that are located inside the wall a
Item A-3: Legal type the company and the registration number in the Palestinian Ministry of National Economy.
Item A-4: Owner information: each field should be filled as described in the table. The ID of each person mentioned in the table should be attached to the application
Item A-5: Top Management: Each field should be filled as described in the table. The ID of each person mentioned in the table should be submitted with the application. At least the General Manager and the Financial manager info should be provided in this table.
Item A-6: Membership: Provide information about the company membership status in the private sector institutions such as chamber of commerce, PalTrade, Unions.
Item A-7: Markets: Specify the market(s) that the company is currently working in
Please follow the following classification:
West Bank, North / Nablus, Tulkarem, Qalqilia, Jenin, TubasWest Bank, South / Bethlehem, Hebron
West Bank, Middle / Ramallah, Al Bireh, Jericho, Salfeet, Al Ram, Hizma, Anata, Abu Dees, Al Eizaryeh
Gaza, North / Beit Hanoun, Beit Laheia, Jabalia
Gaza, South / Khanyounis, Rafah
Gaza, Middle / Gaza, Deir Alabalah, Al-Nossairat, Al-Breij, Al-Maghazi, Al-Zahra
East Jerusalem / The areas of Jerusalem that are located inside the wall and it needs to have permission from Israel to go in such as Beit Hanina, Shu’fat, Silwan, Al Tor, Sor Baher, West Swahreh, etc.
Note: All villages related to each district should follow the district classification
Item A-8: Consultants - Clarify if the company has ever used consultancy services and how was it paid for.
Item A-9: Pervious Donors Assistance – Inform if company benefited from other donor projects, including FNMD project and PMDP.
Item A-10:
Financial Information:
Company financial data for last three years and the projection for the following year. The financial Data is divided into two sections:
- Income Statement:
This statement shows the company’s revenues and expenses during a particular period.
- Balance Sheet:
Financial statement that summarizes a company's assets, liabilities and shareholders' equity at a specific point in time. The balance sheet equation is that total assets equals liabilities plus owner's equity.
For part time employees the question should be answered in a way that describes the average number of hours for the employee per week. For example, if a company has two part time employees. First employee works 2 full days per week, while the second employee works 5 days per week for 2 hours a day . The average will be 13 hours per week (First employee works 2*8 = 16 hours per week, second employee works 2*5 = 10 hours per week, so the average will be 13 hours (10+16= 26/2)
Section B: Project Plan
The purpose of this section is to explain the proposed plan of the company to improve their products/processes, develop new products and enter new markets
Item B-1: Project Plan Summary – list of current products that you plan to expand their markets, products that need to be improved or brand new products. On the other side, list current markets, new local and/or international markets.
Item B-2: Project Summary description – narrative description of the proposed plan.
Item B-3: PMDP Additionality - answer and provide rationale for your answer
Item B-4: Strategy and Plan to achieve objectives- This should include the needed steps to achive the objectives.
Item B-5: Breakdown of activities – fill the table for each activity, estimated cost for this activity and the duration of it.
Section C: Self – declaration
The purpose of this section is to provide a declaration from the company applied to PMDP grants that the company and its owners are in a good legal and financial status. It is also to confirm that the information provided are correct and the company is committed to inform PMDP of any changes happened to the company and its owners. On the other hand, by this declaration the company confirms that the company accepts that this application will pass PMDP evaluation process and will accept the result of this evaluation.
The applicant must carefully read and understand the Self-declaration page, then sign and stamp it.
Note:
Once you completely fill all the application’s items, please send it to or send hard copy to PMDP office.
Ramallah office:
4th floor, Millennium Bldg., Kamal Naser St., Al Masayef Tel: +970 2 2986340, Fax: +970 2 2959220
Gaza office:
6th floor, Al-Thefer 9 Bldg, Qanal St., Al Remal Tel: +970 8 2825888, Fax: +970 8 2825889
(1) All information will be treated in strictest confidence