KWAZULU-NATAL PROVINCIAL GOVERNMENT

IN PARTNERSHIP WITH DUNLOP SOUTH

AFRICA APPLICATION FORM

BUSINESS DETAILS
Name of Applicant:

Age of Applicant:

Registration Number of Business Entity:

Position/Role in relation to the Applicant:

ID no of individual representing the Business Entity:

E-mail:

Tel: Fax: Cell:

Applicants Business Details - address and trading name:

City/Town: Province:

Country: Code:

FUNDING INFORMATION

Requested grant size: To be determined by the project sponsor.

Total Grant Required for the Dunlop Business

in the Box:
□ To be determined by the project
sponsor.

Owner/s Contributions or other funding received or applied to the Business if any:

APPLICATION FORM FOR KZN GOVERNMENT AND DUNLOP PARTNERSHIP BUSINESS IN THE BOX
FUND (EXCLUSIVELY FOR KZN YOUTH)
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R____________________________ Name:
_________________________________________________________
R____________________________
Name:
R____________________________ _________________________________________________________

R____________________________ Name:
_________________________________________________________

R____________________________
Name:
_________________________________________________________

Name:
_________________________________________________________

OWNERSHIP INFORMATION

Shareholders/Beneficiaries
Name & Surname Race ID Number Shareholding
%

Executives/Directors/Trustees/Members/Partners

Name & Surname Race ID Number Role in the

business

Why did you choose to be assisted with the Tyre business? Give brief motivation / explanation
for reasons to choose this industry (provide a page long motivation separately).

APPLICATION FORM FOR KZN GOVERNMENT AND DUNLOP PARTNERSHIP BUSINESS IN THE BOX
FUND (EXCLUSIVELY FOR KZN YOUTH)
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 PERSONAL INFORMATION COLLECTION NOTICE AND CONSENT FORM
Please be advised that by completing this form the Applicant and all entities and or individuals referred
to herein acknowledge that their personal information (hereinafter referred to collectively as “your/your
personal information”) will be required to be disclosed and processed for consideration under the tyre
grant funding contemplated herein to conduct all necessary background checks required in accordance
with South Africa’s Anti-Money Laundering Legislation and FICA processes in-order to assess your
creditworthiness, conduct criminal checks, investigate prior convictions and judgements, validate all
educational certification and employment history, interrogate any other information provided in support
of this application. You hereby grant permission in terms of POIA for your information to be utilised for
the afore mentioned purpose.

In this regard, please note the following in accordance with Protection of Personal Information Act 4 of
2013, as amended from time to time:

• The processing of your personal information complies with obligations imposed by law.
• Your personal information shall not be retained any longer than is necessary for achieving the
purpose for which the information was collected, and all records of your personal information shall
be deleted within 45 days as same is no longer required.
• The integrity of all personal information and authorised Responsible Party and or Data Processor is
protected by taking appropriate, reasonable technical and organizational measures to prevent loss,
damage unauthorised destruction, unlawful access to or processing of personal information.
• You have the right to access and rectify the information collected, including information about the
identity of all 3rd parties who have access to the information.

DECLARATION
The Applicant and all entities and or individuals represented in this application expressly agrees
and warrants that:

1) The below mentioned signatory/is are duly authorised on their behalf and has the
consent of all entities and or individuals referred to in this application to provide the
personal information for the purposes set out above.
2) All information provided in this document and all auxiliary documentation including but
not limited to the Business Plan is true, accurate and complete.

______________________ ___________________ _______________

FULL NAME FOR AND BEHALF OF SIGNATURE

ID NUMBER: __________________________ DATE___________________

The Business Entity and all individuals, directors, shareholders, members, trustees or partners and all
parties represented in this application represent and warrant that:

▪ The information provided in respect of this application is true, accurate and complete.
▪ No litigation, arbitration or liquidation, sequestration or business rescue proceedings are
present, pending or threatened against it. If any such is present, pending or threatened full
details should be disclosed in this application.

□ YES □ NO

Signature of applicant: Date:

APPLICATION FORM FOR KZN GOVERNMENT AND DUNLOP PARTNERSHIP BUSINESS IN THE BOX
FUND (EXCLUSIVELY FOR KZN YOUTH)
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 ADDITIONAL INFORMATION REQUIRED
To be submitted with the application form.
# Detailed checklist: Mark with
an X if
included
The above Application Form fully completed
1
Certified copies of Incorporation/ Registration Documents of the Business
2 Entity
Certified ID copies of Shareholders, Directors, Executives, Trustees or
3 Members of the Business

CVs of Shareholders, Directors, Executives, Trustees or Members of the

4 Business
Certified recent Tax Clearance Certificates or Pin
5
6 Site /Operating Space / Location Documentation, i.e. PTO, Title Deed,
Lease Agreement or intent, etc.

7 Business Plan with the following minimum information:

(a) Business Description, History, Location, Key Suppliers, etc.

(b) Analysis of Market, Customers and Competitors

(c) Analysis of production plan and processes

(d) Human Resources (Company organogram and CVs of key people)

(e) Marketing and Sales Plan

(f) Capital Expenditure Plan (Machinery and Equipment and their costs);

APPLICATION FORM FOR KZN GOVERNMENT AND DUNLOP PARTNERSHIP BUSINESS IN THE BOX
FUND (EXCLUSIVELY FOR KZN YOUTH)
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