Single Investment Fund

Single Investment Fund – Expression of Interest

About your business

1. Name or company name *

2. Company registration number (if you have one) *

3. Your correspondence address (including post code) *

Postcode

4. Project address if different (including postcode)

Postcode

5. Your website address (if you have one)

Year Business was established

6. Company Contact *

Title (Mr/Mrs/Miss/Ms)

Name

Phone Number

Email (providing us with your email address will help us process your enquiry more quickly)

7. Do you operate as part of a group of companies? [Yes/No; if yes give details]

Yes (If yes give details)

8. Brief account of current/proposed business activities and main products/services *

9. Number of current employees (including directors)

Applicant

Group

10. Turnover (from your most recent accounts)

Applicant

Group

11. Balance sheet total (net asset value) from your most recent accounts

Applicant

Group

12. Is the business classed as an SME (Small and Medium-Sized Enterprise)?

13. Has the business previously received grants or other public sector support?
(If so, please supply details below)

Type of Assistance (e.g. Assembly Investment Grant)	Source of Support (e.g. Welsh Assembly Government)	Date Support Accepted (e.g. June 2006)	Amount of Support (£) (e.g. 23,000)

_________________________________________________________________________

About your project

14. Brief outline of your project, including estimated start and finish date *

15. Your estimated project costs

15. Your estimated project costs Category	£
15. Your estimated project costs Buildings – purchase
15. Your estimated project costs Buildings – construction/improvement
15. Your estimated project costs Equipment and machinery
15. Your estimated project costs Fixtures and fittings
15. Your estimated project costs Intangible assets
15. Your estimated project costs Land – purchase
15. Your estimated project costs Land – development/works
15. Your estimated project costs Professional Fees
15. Your estimated project costs R&D project costs
15. Your estimated project costs Specialist consultancy
15. Your estimated project costs Other costs (please specify)
15. Your estimated project costs Total

16. Proposed funding for the project (£’000)

16. Proposed funding for the project (£’000) Source	£
16. Proposed funding for the project (£’000) New share capital / new capital introduced
16. Proposed funding for the project (£’000) New Director’s loan
16. Proposed funding for the project (£’000) Bank and other loans
16. Proposed funding for the project (£’000) Asset finance (not operating leases)
16. Proposed funding for the project (£’000) Overdraft
16. Proposed funding for the project (£’000) Invoice discounting
16. Proposed funding for the project (£’000) Other private funding (specify)
16. Proposed funding for the project (£’000) Other public sector funding (please specify)
16. Proposed funding for the project (£’000) Single Investment Fund support required *

17. What will be the impact of this project on your current employment levels?

Increase

Maintain

Decrease

Number of new full-time/part-time jobs expected to be created.

Full-Time Jobs

Part-time jobs
Estimated annual costs of new employees (basic wages) (£)

18. Would any current jobs be lost if the project does not go ahead?

Yes (If yes, state how many jobs to be lost)

19. Why is Single Investment Fund support necessary to enable this project to go ahead?

20. What will happen if Single Investment Fund support is not awarded?

21. Have you already made any commitment (financial or contractual) to this project?

Yes (If yes give details)

22. Where did you hear about the Single Investment Fund?

Other (please specify)

Applicant’s Name

Email *

Position in business

Data protection Statement: We will use your personal information to help us deal with your query, and for monitoring and statistical purposes. We may disclose your information to other business service providers for these purposes.

We may also contact you to evaluate our service.

Except where required by law, we will only pass on your information with your consent.

We would like to remind you that you have a right to see any information we hold about you, and you have a right to correct any inaccuracies in it.

By completing and submitting this form, you consent to us holding and using your information in accordance with this notice.

Saving this form: please note that currently you can not save this form to your computer, or retrieve it for editing or printing once you have sent it. If you require a copy for your records, please print it out before clicking the ‘submit’ button.