Empowerment Fund Application

SECTION A: APPLICANT’S DETAILS

Name:

Surname:

Identity Number:

Residential Address:

Postal Address:

Cellphone:

Alternative Number:

SECTION B: BUSINESS DETAILS

Enterprise Name:

Company Registration Number:

Physical Address:

Province:

Postal Address:

Business Tel No:

Business Email Address:

Business Location:

Intervention Required:

Stage of Business:

How many Years/Months has your Company been in Existence:

Enterprise Type:

Type of Industry (e.g. Tourism, ICT, Agriculture,Textile):

Name of Municipality:

Ward Number:

SECTION C: ATTACH SUPPORTING DOCUMENTS

1. Covering / Application Letter:

2. Business Profile:

3. Copy of the CIPC Registration Certificate ( CK1 / CK2 / CM29 /CM49):

4. Copy of Tax Clearance Certificate:

5. Copy of BBBEE Certificate/Affidavit:

6. Certified copies of Identity Documents of Directors/Member/Owner:

7. Quotations for Intervention:

8. Copy of the lease agreement/proof of ownership, etc.:

9. Proof of Market (contracts, invoices, receipts, etc.):

10. Financial statement(s) or minimum 12 months bank statements:

11. Proof of annual return submission for Private Companies:

12. Signed and approved minutes (Resolution) for Empowerment Fund:

13. Letter of confirmation of the Business Account:

14. Business Training Certificate:

SECTION D: FUNDED INTERVENTION REQUEST

No.	Description	Supplier	Quantity	Unit Price	Total Value (Incl VAT)
1
TOTAL

SECTION E: MANDATORY QUESTIONS

1. Brief Description of the Business:

2. Motivate why are applying for Empowerment Fund:

3. How will these interventions (i.e. Machinery and equipment) you are applying for assist in sustaining the business operations?:

4. List clients or potential clients (Please include a minimum three (3) reference letters or letters of intent):

5. How many permanent jobs will you create after you have been assisted by this programme?:

6. General / Additional information :

SECTION F: DECLARATION AND CONSENT

I/We hereby declare that the information in this application is a fair and true reflection of our intended project. I am aware of the fact that the information which we have submitted above will have a material bearing on the adjudication of the application. If any information in the application, with the addendum, is not correct, or certain information was omitted, the Adjudication Committee shall be entitled to withdraw or amend its approval and, without prejudice to its rights, to recover any amounts already paid or to withhold further payments due.

I/We hereby declare that this application is on a first come basis, and Department of Economic Development, Conservation and Tourism reserves the right to close applications due to budget constraints.

I/We have declared that I/We are authorised to make this application and I/We have read and understood the criteria and requisite documents in the advert.

I/We authorise you to make any enquiries in accordance with your procedures in connection with this application. .

I confirm the above statement.