Market Access:Application Form
Disclaimer and Importance Notice
- Please read the application in conjunction with the guidelines which detail the legal implication of completing this form.
- Specific attention is drawn to the dti’s rights to cancel any agreement based on incorrect or misleading information provided in this application.
- Entities that make fraudulent applications or claims will be persecuted to the full extent.
Please Note the following before completing the form
- Please Study the guidelines
- Please be aware that the guidelines form art of the agreement with the dti
How to complete this application form
- Complete all the required fields of the applications
- All the fields marked with a red asterisk (*) are compulsory
- Once completed, save form and press submit
How did you find out about the Black Industrialist Program
Road show/ Exhibition/ Presentation the dti website
the dti Regional Office Provincial Government
Advertisement, TV, Radio, Print NCPC
the dti Group Word of Mouth
Other
If other please provide more information
- Applicant Company Details
- Company Details
Registered Company Name *
Company Registration Number *
Company Business Address *
Company Web Address *
Company Telephone Number *
Company Fax Number
Sector and Product/s *
Company Contact *
Company Contact Person *
Email Address *
Project Summary - Please provide us with you current market summary * (Marketing strategy may be attached)
Critical Market – Please provide us with the identified critical market, including geographic location as well as segment * (additional information may be attached)
1.2.Eligibility Criteria
Kindly tick in the response box
I confirm that:
The company is in the manufacturing sector of the economy *
The company has >50% Black ownership *
The company is productive sectors of the economy aligned to IPAP *
Exercises control of the business, (Shareholding, Management and Control is Black South Africans) *
Have taken personal risk *
Company is in Good standing with SARS *
Product is a manufactured in South Africa *
- Company Profile
- Company Overview
Profile may be attached*
- Please give a brief outline of the company history.
- Please briefly summarise your current product/service and key markets
- Where relevant, please provide information on group structure, etc.
2.2.Company Ownership*
Black Industrialist Market Access Application Form
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Shareholder Name / ID Number / Country / % Shareholding / Gender / Race / Position HeldTotal
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- Identify any connected companies and related parties and outline their relationships.
- Business Strategy
- Product/Service and Market
Additional information may be attached*
- What is the product/service that you supply now and what is its Unique Selling Point (USP)?
- What is your specific target market? Please quantify?
- Who are your main competitors?
- Why is your product/service better than that of your competitors i.e. price, functionality, service etc.?
3.2Business Model
Additional information may be attached*
- What channels do you use to bring your product/service to your customers and markets?
- What is the pricing model used to achieve your sales revenue?
3.3Management
Additional information may be attached*
- Outline the current management structure.
- What are the key skills/qualification and track record of the current management team and advisers?
- Are there any potential gaps in this management structure?
4Other Support Required
Non-financial support / Yes / NoThe Company requires:
Technical and Vocational Training
Mentorship and Support
Match-Making and information sharing
Research and Innovation support
Quality Standards and productivity Support
Other incentives
Other support, elaborate below
5Declaration by Authorised Officer of the Applicant
I declare that the information provided in this application is true and fair
Accepted By * ______
Capacity *______
Date Accepted*______/______/20
The Following Documents should be attached
- Completed application form
- B-BBEE Certificate
- A valid Tax Clearance Certificate
- Incorporation Certificate
- Latest audited annual financial statements
- Company Profiles
- Catalogue of product and services
- Marketing Strategy
Black Industrialist Market Access Application Form
March 2016Page 1 of 6