MOMBASA COUNTY GOVERNMENT
OFFICE OF THE GOVERNOR
YOUTH,WOMEN AND PERSONS LIVING WITH DISABILITY(PWDS),REVOLVING FUND
APPLICATION FORM
2016/2017
Overview
Thank you for your interest in the Mombasa County Government Youth, Women and Persons
Living with Disability (PWDs) Revolving Fund Board.
The Revolving Fund Board has been established by the Mombasa County Government in order to
provide limited grant funding to Youth, Women and PWDs to start up Businesses within the
county. The funding will mainly be allocated in the form of a revolving loan. Funding ranges
between Ksh 50, 000 and Ksh100, 000.
General Eligibility Requirements for Revolving Fund
To be eligible for the funding, all youth, women and PWDs groups and Businesses must complete
the attached application form.
General criteria for selecting Youth Businesses
In determining which applicants among all those submitting applications will be considered for
funding, the COUNTY GOVERNEMENT OF MOMBASA REVOLVING FUND BOARD considers and
weighs those Youth, Women and PWDs Businesses that submit evidence of the following criteria:
1. The group must be legally registered under the Social Development Office or any other
recognized form of registration by the government of Kenya (attach copy);
2. Business is or will be a legally registered business;
3. Business has clearly defined, measurable and achievable goals and objectives;
4. Your application should adequately describe the managerial, financial and technical
capability of the business to be viable;
5. Members of the group must have attended entrepreneurial training from the accredited
organization / institutions through the department of Youth, Gender and Sports.
6. Supporting documents is attached to the application.
7. Each applicant must complete the attached Verification form. If not completed, your
application will not be considered.
SECTION A: VERIFICATION
CONTACT INFORMATION
1.
Name of your organization ___________________________________________
(a). Name of business: ___________________________________________________
(b)Application Date__________________________________________________
2.
Address:
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3.
Telephone:___________________ Cell phone:______________________
Fax:________________________
Email Address:______________________________________________
Website Address:____________________________________________
4.
Sub-county where business is or will be located:_______________________
5.
Are you, your staff or business partner/s currently related to anyone employed at the
County Government of Mombasa?
Yes/No: ____________________________________
BACKGROUND INFORMATION ON BUSINESS
1.
When was your business established?
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2.
Is your business registered?
Yes_____
No_____
In process___________________________________
Form of Business _______________________________________________
3.
If answer is yes, please attach a copy of the business registration document.
If answer is in progress, when did you apply for registration?
4.
Have you been through business mentorship programme?
Yes____ No ______. If yes, name the organization that provided that service.
5.
Have you been through any training on Business? Yes____ No______
If yes, give the name of the organization that provided the service. _______________
5.
Who manages the business?
6.
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How many owners are there?
Men___ Age(s)_____________Women___ Age(s)______________ Disabled __________
How many full time employees are there?
Men___ Age(s)_____________Women___ Age(s)______________ Disabled ___
How many part time employees are there?
Men___ Age(s)_____________Women___ Age(s)______________ Disabled ___
7.
In chart below provide the requested information about your Group Members:
Name
8.
How long has your business been in operation?
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Title
Full
time
Part
time
Educational
Background
The undersigned persons acknowledge that the information provided is correct
Please write the names in print.
Name: …………………………………………………………………………………………..
Signature:………………………………………………………………………………………
Date:…………………………………………………………………………………………………
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;
Group Patron/Referee (Name)……………………………………Community
Leadership position………………………………
Signature……………………Date………….…..Contact………………………
NB. 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, what the overall strategy is, and how much money is required to start.
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1. BUSINESS DESCRIPTION
Short description of the business and what it does.
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2. BUSINESS OPERATIONS
Longer description of the business, what it does, how, etc. Describe the concept and exactly how
the business will work. If applicable, please list important suppliers and contracts that you have.
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3. MARKET AND COMPETITION
3.1 Environment Analysis
Describe the overall context of the business. Why is this the right place, time, etc for this business
to be operating.
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3.2 Target Market Analysis
Describe the clients. Who are they, why would they buy from you or make use of your services?
What is it they’re looking for?
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3.3 Competitor Analysis
Who are your major competitors? What are they doing right? And wrong? If new and upcoming
business, what will they do to respond to your business?
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4. MARKETING PLAN AND STRATEGIES
4.1 Strategies
What is the company going to do to break into the market? If a new and upcoming business,
demonstrate simple strategies that your business plan to use to attract your first customers.
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4.2 Timeline
A strategy is no use without a detailed layout of the objectives, tasks and length of time (or due
dates) associated with each task. List these.
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ORGANISATION STRUCTURE AND HUMAN RESOURCES
4.3 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).
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4.4 Organisation Structure
A large organisation structure is not necessary. However, a description (or visual representation)
of how the various aspects of the business relate to each other will be helpful.
5. FINANCE
Established businesses are required to provide financial statements which must be attached to this
application form.
In case of start-ups (Use projected financial estimates).
6.1 Owners Contribution
Specify what the owner will contribute to the business.
Owner’s contribution (eg. stock, equipment,
cash)
Estimated value in Kenya Shillings
Total owner’s contribution:
6.2 Total investment and funding requirements
Item
Source of funding
Value
Owners
equity
Bank loan/
Grant
Other
creditors
6.3 Monthly cash flow statements
Please project what the monthly movement of cash will be into and out of the business.
Particulars
Cash Inflow
Total Cash Inflow
Cash outflows
Total Cash Outflow
Ending balance
Preoperating
Months
1.
2.
3.
4.
5.
6.
7. Funding Required
Specify exactly how much funding is needed and what it will be used for.
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8. CONCLUSION
A short, summary, repeating what the business is, why it will be successful and why it should be
supported.
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SECTION D: 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.
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2.
State the objectives of the business and explain how the proposed business will address
the developmental problem(s) in your community as stated above?
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3.
Have the business previously received funding from government? If yes, what type, under
which programme, and how much?
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4.
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
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Funds Management Committee use only
Name of
official
Recommendation
Yes
No
Comment
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---END—
MOMBASA COUNTY GOVERNMENT
OFFICE OF THE GOVERNOR
YOUTH,WOMEN AND PERSONS LIVING WITH DISABILITY(PWDS)
REVOLVING FUND BOARD
POLICIES AND PROCEDURES
EVALUATION CRITERIA
The Youth,Women and Persons Living with Disabilities (PWDs)Revolving Fund Board will use
the underlisted criteria to evaluate application forms for funding from registered group.
Submission of dully filled loan application forms
The groups must be registered by the registrar of company and or department of Social services
where applicable
The groups must attach copies of National Identity card
1. The group must have a bank account from a recognised financial institution
2. In the case of limited liability company and or registered business name,the group
must have PIN and VAT certificate
3. The size of the registered group must be between 5-20 members and must indicate
physical location of the business
4. The group must attach minutes of the meetings hels for the last six months outlining
the group resolutions
EVALUATION PROCEDURE
The revolving fund board will use the underlisted procedures to process proposal received from
Youth,Women and PWD’s.
1. Recieve proposals dully filled in the prescribed format
2. Internally sort the proposals based on the set criteria
3. The board will verify the existance of the group from the Registrar of Company and or
department of Social services
4. The board will allocate code and ensure data has been entered in the system
5. A sub-committee will be formed to evaluate the proposals recieved and do site visit where
applicable
6. The sub-committee will make its recommendations to the board for approval of the proposal
or any other advice as the board deems fit
7. The fund manager will diburse cheques on all approved proposals by the board
EVALUATION FLOW CHART
RECIEVE PROPOSALS
SORTING,VERIFICATION
AND
DATA ENTRY
EVALUATION AND SITE VISIT
RECOMMENDATIONS AND
BOARDS APPROVAL
DISBURSEMENT OF FUNDS