BRAC MAENDELEO TANZANIA

LEAD PROJECT INVESRMENT FUND, 1st ROUND – APPLICATION FORM Page 1 of 16

SECTION A:YOUR COMPANY

Company Details

A1. / Company name ………………………………………………………………
A2. / PO Box ………………………………………………………………
A3. / Address (physical) ………………………………………………………………

Contact details

A4. / First name ………………………………………………………………
A5. / Surname ………………………………………………………………
A6. / Job title ………………………………………………………………
A7. / Email address ………………………………………………………………
A8. / Mobile number ………………………………………………………………

Business Details

A9. / Core business activity
☐Production
☐Processing
☐Breeding
☐Trading
☐Service
☐Other (please specify)………………………………………………………………
A10. / Do you own or are you renting your current facility?
☐Owning
☐Renting
A11. / What is the ownership agreement of the business?
☐Individual
☐Shared
☐Other (please specify)………………………………………………………………
A12. / Year established ………………………………………………………………
A13. / First year business was registered …………………………………………………
A14. / Annual turnover ………………………………………………………………
A15. / No. of full-time employees ………………………………………………………………
A16. / No. of part-time employees ………………………………………………………………

Company Registration

A17. / Business registration number. ………………………………………………………………
A18. / Business registration expiry date …………………………………………………………..
A19. / Name of bank of the business, Address and Account No. ………………………………………………………
A20. / Is the business a tax payee?
☐Yes
☐No
If yes, TIN ………………………………………………………………
A21. / Are you an m-Pesa customer or Tigo pesa customer?
☐Yes
☐No

A22. Company’s Current Activities

What does your company do? (include all activities and not just those activities that are related to poultry and maize)

A23. Products and Services of the Company

What are all the current products you sell and/or all the services you currently offer?

Product/Service / Price/Cost / Unit / Description

A24. Distribution Network

Where are you currently selling your products and/or providing your services? (specify the city, the regions, and provide the name of the distributor and/or agent)

A25. Operation and Management Challenges

What are your current operational and management challenges?

A26. Monthly Sales and Expenses

What were your company’s SALESfor the last completed month and the before last complemented month?

LAST MONTH / MONTH BEFORE LAST
Sales / Sales
Item / Unit Cost / Total Quantity Sold / Item / Unit Cost / Total Quantity Sold

What were your company’s EXPENSES for the last completed month and the before last complemented month?

LAST MONTH / MONTH BEFORE LAST
Expenses / Expenses
Item / Total Expenditure / Item / Total Expenditure

A27. Company and Personal Assets

What are your company and personal current fixed assets? (include land, vehicle, buildings, and machines)

Description / Quantity / Purchase Price / Year of Purchase / Depreciation/Appreciation
of one year / Remarks

SECTIONB:YOUR BUSINESS PROJECT

Project details

B1. / Type of business project ………………………………………………………………
B2. / Where will your business project be implemented?
Region (s) ………………………………………………………………
City/Cities ………………………………………………………………
B3. / Economic sector
☐Maize
☐Poultry (incl. meat and eggs)
B4.
B5.
B6.
B7.
B8.
B9.
B10. / Business Project Description
What would you like to do (i.e. what are your project objectives)?
Carrying-out your Business Project Objectives
What are the key steps to carrying-out your business project (i.e. how will you achieve the above mentioned objectives)?
Target Customers and Marketing
Who will be your target customers (also include information on which cities and regions they will be located) andhow you plan on attracting them (i.e. your promotion and marketing strategies)?
Collaboration with LEAD Maize and Poultry Farmers
How will you work with poultry and/or maize farmers through your proposed business project?
Current Capacity
Describe your current capacity to implement this business project – what experience, equipment, material, and resources do you currently have available?
Experience
Human Resource
Raw Material
Equipment
Infrastructure
Land
Challenges and Risks
What challenges and risks do you perceive in implementing your business project?
How do you plan on addressing and mitigating the above risks/challenges?
Competition
Who are your major competitors?
How do you intend to differentiate your product/service from your competitors?

SECTIONC:FINANCIAL DETAILS

C1. / ProjectedBudget
Provide a detailed proposed budget for your project(including but not limited to purchases to be made in material, investments in equipment, employees to be hired, salaries to be paid, inputs used, etc.…)
C2.
C3. / Total Financing
What is the total financing for the business project? (refer to your budget total) …………………………(specify ifamount is in USD or Tsh)
Contribution
Based on the indicated amount in C2, how much financing can you provide yourself? ……………………………...... (specify ifamount is in USD or Tsh)
C4. / Third Resource Financing
Do you have or plan to have a third source of funding besides yourself and BRAC?
☐ Yes
☐ No
If yes, please provide information on the source (specify if it is a current or intended source, amounts, and length of support, etc.)
C5. / Financing Request from BRAC
Based on C2, C3, and C4, how much financing are you requesting from BRAC– including grant + loan amounts? ………………………………...... (specify ifamount is in USD or Tsh)
Amount must be at least5,000 USD/8,000,000 Tsh and no more than30,000 USD/50,000,000 Tsh
N.B. The amount requested should not be more than 50 percent of the value of your current investment (including assets and your business’ value)
C6. / Previous loans
Has your company received any loans in the past 5 years?
☐Yes
☐No
Ifyes,pleasestatethenameofthelender,theamountofthefundsreceived, theyeartheloan wasapproved, and the date the loan is scheduled to be fully repaid or was fully repaid.
Lender 1 / Lender 2 / Lender 3
Name of lender
Amount (specify USD or Tsh)
Current balance (specify USD or Tsh)
Year approved
Loan repayment completion date
C7. / Financial Accounting
Are there existing practices of financial management in your business?
☐Yes
☐No
Who is responsible for the record keeping?
Name: …………………………………………………………………………………
Title: …………………………………………………………………………………..
Financial Accounting / Preparation of quarterly and annual financial statements / Accounting system
(select only one)
☐cash
☐accrual / (select only one)
☐in-house
☐outside independent accountant / (select only one)
☐manual
☐computerized

Note: ALL INFORMATION COLLECTED THROUGH THE APPLICATION PROCESS WILL REMAIN CONFIDENTIAL AND WILL NOT BE SHARED WITH ANY AUTHORITY OUTSIDE OF BRAC.

I certify that the information supplied with this application is correct to the best of my knowledge.

Date:…………………………………Name:………………………………………

Signature:…………………………………

SECTION D: CHECKLIST OF SUPPORTING DOCUMENTS

Please include the following documents when submitting your application

☐ Copy of business or trade license registration

☐ Copy of tax identification or vat registration certificate

☐ Copy of legal documents (Memorandum and Article of association/Partnership agreement/Cooperative society documents/TIC certificate)

☐ Information of yearly sales OR balance sheet

☐Company bank statements reflecting the last 3 months’ activity

☐Latest financial accounts or income and expense worksheet