Please complete the below application form with the current and relevant details of your business and submit to replicaneurs@impacthub.net
before
27/November/2015
Product or Idea Description:
The application form has clear cut fields where you have to describe your business concept that you plan to pitch for, in a few lines. It would be a good idea to plan ahead while you put your concept into words in the application.
Business Information:
The name and basic information of the business or the company that you run has to be mentioned in the application. Applications that do not have a business or company to project in the application do not stand a chance to get selected for the program.
Personal Information:
Personal information in an application refers to any information that is important and would interest the judging panel. It could be an achievement, award, previous inventions, and ideas etc. that have been appreciated by other stakeholders.
Business Model Overview:
Here’s your chance to elaborate on the product or idea that you have developed. This section of the application requires you to give a comprehensive view of your product or service. The outline has to be clear and should state the areas that your idea can be applied to and the problems that your idea can solve. An application should clearly state details of any copyright or patent protection that you have applied for. Details pertaining to testing and prototyping should be included in the application. Any other additional information regarding your product or idea that you deem fit can be added in this section of the form.
Business Plan:
If you have a current business plan and you would like to attach it to this application, it is permitted; however, it is not required.
PROGRAM PARTNERS:

ABOUT YOUR ORGANIZATION:
Company Name:
Date Established:
Founders:
Number of years being an entrepreneur:
Current Number of Employees:
Location of Headquarters:
Men: Women:
Other Locations (number and place):
Industry or Sectors:
Activities:
Management Team Overview (including background and expertise):
Social Impact of your business:
PROGRAM PARTNERS:

Market Opportunity in Current Location:
Briefly explain your business model:
Do you currently operate a profitable social enterprise?
What are the USP’s of your proposition?
What are the biggest challenges you came across while setting up your current business?
Which parts of your proposition specifically would drive replicating your business?
What would replication look like (in your opinion)?
What is fundamental to your business model that makes it work in another local context?
Please describe the fundamental elements of the business model.
Do you have a clear overview of cost structures and revenues? And can you provide us with an overview of cost- and revenue flows?
How would your model be scaled into other markets:
PROGRAM PARTNERS:

YOUR ORGANIZATION’S TEAM:
How much time are you willing to invest during the validation and start-up phase
(hours/week)?
What activities will you do or can you perform yourself?
Do all stakeholders (from staff to the board & external stakeholders) support replication?
What do you expect from the local replicator (e.g. qualifications, experience, skills)?
What training and support is required to enable the local replicator to fulfill their role effectively?
What are the start-up costs (Capital & Operational expenses)? Can you specify these?
Percentage of local market share:
Plan for growth in current location:
PROGRAM PARTNERS:

Existing funding base and shareholders, type of future potential ones
Describe current financials: revenues, gross margin, break-even date
Annual growth over the past 3 years?
Major competitors in current market:
Initial perception of competition in Rwanda:
Why are you interested in this program?
Why now?
Why should we select you?
What are you looking for out of this experience?
Are you able to spend $10,000 USD on consultancy for this program?
PROGRAM PARTNERS: