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DEVELOPMENT FUNDS APPLICATION FORM

                                                                            

 YGP2                                    

YGP1

MOMBASA COUNTY GOVERNMENT

OFFICE OF THE GOVERNOR

 

YOUTH,WOMEN AND PERSONS LIVING WITH DISABILITY(PWDS),REVOLVING FUND

 

APPLICATION FORM

2016/2017

SECTION A: VERIFICATION

 

CONTACT INFORMATION

 

  1. Name of your Group ______________________________________________________

 

(a) Nature of business: ______________________________________________________

        

(b) Application Date________________________________________________________

 

  1. Address: ________________________________________________________________

 

  1. Cell phone: ______________________

 

Email Address: ______________________________________________

 

Bank_____________________________________________Branch_________________

 

Bank Account No____________________________________

 

  1. Where the business is or will be located:

 

  1. Sub-county _______________________

 

  1. Ward _____________________________

 

When was your business established?

__________________________________________________________________

 

  1. Have you been through any training on Business? Yes____ No______

 

If yes, give the name of the organization that provided the service.   _______________

 

  1. In the chart below provide the requested information about your Group Members

 

Name Gender Title Person with disability Educational background
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         

 

GUARANTEE 

We the undersigned below hereby confirm that we are bona fide office bearers of ……………………………………………………………. Group and declare that the information given herein is true to the best of our knowledge. We further affirm that we have read and fully understood the content of this loan agreement. We understand that the amount given here is a loan and must be repaid on due date. We hereby guarantee and commit the group to redeem the loan to the satisfaction of Department of Youth, Gender and Sports Mombasa County Government.

 

(a)Chairman…………………………..ID/No……………..Signature…………….Date……….Contact………………….

 

(b)Secretary………………………….ID/No……………..Signature…………….Date………..Contact………………….

 

(c)Treasurer…………………………. ID/No……………..Signature…………….Date………..Contact…………………

 

Witnessed by; 

Ward Administrator

Name………………………………………………………………………………………….

 

 

Signature…………………………….…..Official Stamp…………………………………

 

 

  1. ALL GROUP MEMBERS TO ATTACH NATIONAL ID PHOTOCOPY (MANDATORY)

 

 

 

 

SECTION B: BUSINESS PLAN

Executive Summary

 

A brief description of what the business is, who the market is, why the business is likely to be successful, and how much money is required to start.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

Organisation Structure and Human Resources

 

  • Management and Support Personnel

 

Give a brief description of the people behind the organization / business.  The full cv’s must be attached at the end, so these are very brief descriptions of who people are, what their experience is and what they will be doing (i.e. what are they responsible for).

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

 

Finance

2.1 Owners Contribution

Specify what the owner will contribute to the business

 

2.2 Total investment and funding requirements

 

 

  Source of Funding
Item Cost Owners contribution Requested  amount
       
       
       
       
       
       
       
       
       
       
       
       
       
       
        

 

  1. Conclusion

 

A short, summary, repeating what the business is, why it will be successful and why it should be supported.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 


SECTION C: PROJECT DESCRIPTION

 

  1. Why is the business needed? Please state the developmental problem(s) you plan to address as a community member with your business and the proposed business location and/or address.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

  1. State the objectives of the business and explain how the proposed business will address the developmental problem(s) in your community as stated above?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

  1. Have the business previously received funding from government? If yes, what type, under which programme, and how much?

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

  1. List two references who can vouch for the integrity, reliability and usefulness of your business or business idea.

 

Reference (1)                                                              Reference (2)

 

Name: _____________________________ Name: _______________________

 

 

Contact Information                                                 Contact Information

________________________________________________________________________________________________________________________________________________

 

 

 

Funds Management Committee  use only

 

Name of  official Recommendation Comment
Yes No
       

 

………………………………………………………………………………………

 

………………………………………………………………………………………

 

……………………………………………………………………………………

 

………………………………………………………………………………………

 

………………………………………………………………………………………

 

……………………………………………………………………………………

 

 

 

 www.mombasa.co.ke

 

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DEVELOPMENT FUND APPLICATION FORM