SHANDUKA BLACK UMBRELLAS MEMBERSHIP APPLICATION FORM

Please complete the form online, or download it by clicking here, you can then print, complete and return the form to us.

ENTERPRISE DETAILS

To which branch are you applying Cape Town Johannesburg Pretoria

Enterprise Name

Enterprise type PTY (LTD) CC OTHER (PLEASE SPECIFY) PARTNERSHIP SOLE PROPRIETORSHIP

Names of directors / members

Business telephone no.

Primary contact person & contact number

Business email address

Physical Address

Is the enterprise registered for income tax?No Yes

Briefly state the enterprise’s core business activity

OWNER BIOGRAPHICAL QUESTIONNAIRE (please specify for ALL directors / members of the enterprise)

Member

Member name

Member surname

Age 18-24 25-34 35-44 45-54 55-64

Gender Female Male

Population Group Asian Black African Coloured Indian

Level of Education Degree Diploma Grade 11 or below Grade 12

Member

Member name

Member surname

Age 18-24 25-34 35-44 45-54 55-64

Gender Female Male

Population Group Asian Black African Coloured Indian

Level of Education Degree Diploma Grade 11 or below Grade 12

Member

Member name

Member surname

Age 18-24 25-34 35-44 45-54 55-64

Gender Female Male

Population Group Asian Black African Coloured Indian

Level of Education Degree Diploma Grade 11 or below Grade 12

Sector your business operates in (Please tick) Business Services (finance; insurance and real estate) Consumer Services (retail; motor vehicles; lodging and restaurants; personal services; education and recreational services) Extractive Sector(agriculture; forestry; fishing and mining) Transformative Sector(construction; manufacturing; transportation; communication; utilities and wholesale distribution)

How many people do you expect to employ within the next 3 years? 10 or more Less than 4 More than 4 but less than 10

How long has your business been trading? Between 1 and 3 years Between 3 months and 1 year Less than 3 months More than 3 years (please specify number of years)

Trading Duration (If your business has been trading for longer than 3years)

What is your primary motivation for starting this business?

Please state the primary motivation for enlisting your enterprise to be a part of the Shanduka Black Umbrellas programme?

Do you believe you have knowledge, skills & experience to start a business? (Please tick)No Yes

Are you aware of good business opportunities?No Yes

Do you believe you have entrepreneurial capabilities?No Yes

Do you personally know an entrepreneur?No Yes

Do you see entrepreneurship as a good career choice?No Yes

QUALIFICATIONS, SKILLS AND EXPERIENCE

Proven industry knowledge, qualifications and experience

Part of the screening process is to establish whether as a business owner you have a demonstrable experience in the type of business that you are currently conducting or wish to enter into. We need specific information pertaining to studies undertaken in that particular field, work experience gained for a company in the field, skills developed in the field and / or a combination of all of these.

Qualifications

Member

Member name

Member surname

Name of institution

Qualification obtained

Period of study

List major and final year subjects

Member

Member name

Member surname

Name of institution

Qualification obtained

Period of study

List major and final year subjects

Member

Member name

Member surname

Name of institution

Qualification obtained

Period of study

List major and final year subjects

Work Experience

Member

Member name

Member surname

Name of company

Position

Period of employment

Experience acquired

Member

Member name

Member surname

Name of company

Position

Period of employment

Experience acquired

Member

Member name

Member surname

Name of company

Position

Period of employment

Experience acquired

Finance

What was the average monthly turnover of the enterprise for the past year?

How much money is your business going to need in order to run effectively for the next 12 months?

Please attach projected running costs of the business for the next 12 months (highlighting your own income / salary expectations. (Max Pdf or Word doc. size 600KB)

What will be the primary source of capital for the business during the 12 month period? [considering the fact that it may take a few months before the business is able to generate cash of its own] Other (please specify) Own capital (from savings etc.) Personal loan (please specify)

Source of Funding Notes

Market

List at least three major competitors to your product and / or service:

Give an indication of who your existing and / or potential customers for the product / service are:

Please attach a certified copy of the Owner's/members/shareholders ID documents. (Max Pdf or Word doc. size 600KB)

Please attach a certified copy of the businesses CK and other relevant registration documents. (Max Pdf or Word doc. size 600KB)

By accepting, I / we hereby certify that
- the company / close corporation is 100% black owned.
(Black Owned means that 100% of the shareholding, if a company, or members interest, if a Close Corporation, in the Enterprise is owned by Black People. If the Enterprise is a partnership then 100% of the partners shall be Black People. If the Enterprise is a sole proprietor then the Enterprise shall be owned and operated by a Black Person. Black People/Person means African, coloured or Indian persons who are South African citizens by birth or by descent or who were naturalized prior to the commencement of the interim constitution in 1993. It also includes black people who became South African citizens after the constitution,s commencement but who would have been able to be naturalised prior to this, were it not for Apartheid laws which prohibited naturalisation of certain persons.)
- the owner(s) / member(s) / shareholder(s) are neither employed in a full time capacity nor studying full time.
- the owner(s) / member(s) / shareholder(s) do not have a criminal record.

I

ID number:

hereby:
- certify that the information provided by me in this application form is accurate and complete in all respects
- confirm that the information has been provided by me freely of my own accord and understand that it is to be used by Shanduka Black Umbrellas to assess my eligibility to enter into a contract for support services provided by Shanduka Black Umbrellas
- agree and authorise that Shanduka Black Umbrellas and/or its authorised agents to make my name, surname and identity number and/or fingerprints available to the South African Police Service, and educational institutions, credit bureaus and where necessary to request the South African Police Service, educational institutions, credit bureaus to furnish personal information regarding my criminal background, criminal history, previous conviction/s and/or any other relevant information such as usually furnished by the criminal record centre of the South African Police Services and/or educational institution in this regard to Shanduka Black Umbrellas and/or its authorised agent
- agree that Shanduka Black Umbrellas may use the information contained in this application form for research and marketing purposes
- agree that the provision of information in this application form shall not create a legal agreement in any shape or form between the Parties nor authorise either of the Parties to incur any liability on behalf of the other of them, except to the extent expressly provided for in this document.

 

I accept the Terms and Conditions

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