Black Country Local Enterprise Partnership

Funding Expression of Interest Form

Project Overview

Commercial in Confidence

1a. Project Title / 1b. Project Duration (weeks)
1c. Est. Start Date / 1d. Est. End Date / 1e. When do you require the funding to be in place?
1f. Total cost of Project / 1g. Grant Finance required

Applicant Details

2a. Company Name / Started Trading
2b. Company Address (incl. postcode)
2c. Company Registration Number / Are you a family
business? / Yes/No
2d.Contact Name
2f. Email Address / 2g. Tel No.
2h. Which Local Authority do you pay your Business Rates to?
2i. Are you working with any Consultants
who are supporting you with this bid and/ or delivery of project? / Yes / No
If yes, are you happy for us to copy them in to any correspondence?
Please provide their details below: / Yes/No
Business Name:
Contact Name:
Contact email
2j. What is your main Business Activity
2k. SIC Code (for office use only)
2l. Number of FTE Employees / 2m. What percentage is controlled by a non SME?
2n. In the last 3 years have you, or any associated companies, delivered
projects using or have been awarded public sector funding? If so when and how much?
2o. If your business is part of a group, please provide turnover & employee
numbers for the entire group.
Who is the (Global) ultimate owner or parent company / Turnover / £
Number
2p. What sectors does the business supply?
2r. What proportion of sales are exported?
Key Financial Data (Please complete approximate data below for the last 3 years)
Year ended
£000s / £000s / £000s
2s. Turnover / £ / £ / £
2t. Net profit before tax / £ / £ / £
2u. Balance sheet net worth / £ / £ / £

Project Details (only complete 3a, 3b and 3c if you are applying for a grant for premises improvements)

3a. Investment location (including address and postcode)
3b. Site Area or existing built floor space
3c. Is planning consent in place, if required?
3d. Number of jobs you expect to create (full time)
3e. Number of jobs to be safeguarded (full time)
3f. What training does the project involve and what will it cost?
3g. What research and development does the project involve and what will it cost?
3h. What potential is there for any other improvements such as reducing carbon dioxide emissions or involving the local community?
3i. Have you prepared a business or investment plan, including a cash flow forecast, for the project? / Yes/No
If No. What items do you have? (Please tick)
Business Plan
Investment Plan
Cash flow Forecast
3j. Briefly outline what it is that
you want to do and why:
3k. How will you fund your project?
Type of Funding / Provider / Funds
Your own money (new investment by Partners/Directors) / £
Borrowed Funds (Overdraft) / £
Borrowed Funds (Loan) / £
Equity (3rd party investment) / £
Other Funds (Please specify what) / £
Other Funds (Please specify what) / £
Other Funds (Please specify what) / £
Grant(s) applied for / £
Total Project Cost (to agree with 1f above) / £
3l. Why does the business need a grant?
3m. What, if any, other forms of finance have you explored and why are they not suitable?
3n. What external advice have you had regarding finance? (e.g. meetings with accountants, brokers or
other financial consultancy professionals)

Data Protection

The Data Controller is Black Country Consortium Ltd.

Details that you provide us with on this form on subsequent forms or by other means will only be used in connection with business support services offered by Black Country Consortium and partners (Dudley MBC, Sandwell MBC, Walsall

MBC, Wolverhampton CC, the University of Wolverhampton, Birmingham City Council and the Business Growth Service). Information you provide may be input to a computer based recording system and/or paper record to enable us to inform you of related services and for statistical and research purposes

Please send completed forms to