Single Investment Fund – Expression of Interest

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)

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 (If yes give details)
No

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)

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

15. Your estimated project costs

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

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

Source	£
New share capital / new capital introduced
New Director’s loan
Bank and other loans
Asset finance (not operating leases)
Overdraft
Invoice discounting
Other private funding (specify)
Other public sector funding (please specify)
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)
No

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)
No

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

Other (please specify)

Applicant’s Name

Email *

Position in business

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Single Investment Fund – Expression of Interest

About your business

About your project