Black Country Local Enterprise Partnership: Funding Expression of Interest Form
Data Protection
The Data Controller is Black Country Consortium Ltd.
Details that you provide us with on this form on subsequent forms or by other means will only be used
in connection with business support services offered by Black Country Consortium and partners
(Dudley MBC, Sandwell MBC, Walsall MBC, Wolverhampton CC, the University of Wolverhampton,
Birmingham City Council and the Business Growth Service). Information you provide may be input to
a computer based recording system and/or paper record to enable us to inform you of related services
and for statistical and research purposes
1.
Project Overview
1a. Project Title
2.
1b. Project Duration
1c. Est. Start Date
1d. Est. End Date
1f. Total cost of Project
1g. Finance required
1e. When do you
require the funding
to be in place?
Applicant Details
2a. Company Name
2b. Company Address including postcode
2c. Company Registration No
2d.Contact Name
2f. Email Address
2h. Which Local Authority do you pay
your Business Rates to?
2i. Are you working with any Consultants
who are supporting you with this bid
and/or delivery of project?
Is the business a family business?
2g. Tel No.
Yes
No
If yes, are you happy for us to copy them in to any correspondence?
Please provide their details below:
Contact Name
Email Address
2j. What is your main Business Activity
2l. Number of FTE Employees
2k. SIC Code
2m. % Control
by non SME
2n. Have you, or any associated companies, in the last 3 yrs delivered
projects using or have been awarded public sector funding? If so when
and how much?
2o.. If a part of a group please provide turnover/employee numbers for
the entire group, who is the (Global) ultimate owner or parent company
Turnover
Number
2p. What sectors does the business supply?
2r. What proportion of sales are exported?
Key Financial Date - Please complete approximate data below for the last 3 years
Year
£000s
2s. Turnover
2t. Net profit before tax
2u. Balance sheet net worth
£000s
£000s
3.
Project Details
3a. Investment location (including address and postcode)
3b. Site Area or existing built floorspace
3c. Is planning consent in place, if required?
3d. Number of jobs you expect to create (full time)
3e. Number of jobs to be safeguarded (full time)
3f. What training does the project involve and what will
it cost?
3g. What research and development does the project
involve and what will it cost?
3h. What potential is there for any other improvements
such as reducing carbon dioxide emissions or involving
the local community?
3i. Have you prepared a business or investment plan,
including a cashflow forecast, for the project?
3j. Briefly outline what it is that you want to do and why:
3k. Why is your bank unable to fund the project?
3l. Why is the business unable to fund the project?
3m. What other forms of finance have you explored and
why are they not suitable?
3n. What external advice have you had regarding
finance, e.g. meetings with accountants, brokers etc?
Please send completed forms to rgf@blackcountryconsortium.co.uk