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

  1. Applicant Company Details
  2. 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

See Reference Document for further details. / Yes / No
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 *
  1. Company Profile
  2. 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*

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March 2016Page 1 of 6

Shareholder Name / ID Number / Country / % Shareholding / Gender / Race / Position Held
Total

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  • Identify any connected companies and related parties and outline their relationships.

  1. Business Strategy
  2. 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 / No
The 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