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CLEANSTART ENERGY ACCESS CHALLENGE
EXPRESSION OF INTEREST (EOI) FORM
1.
Project title (concise, easily understandable)
2.
Lead enterprise details
Company name:
Legal form:
Start of operations (Year/Month):
Core business model & growth trend to date (e.g. # of units sold, geographic area)
3.
Describe your business idea. What market gap does it help to address?
4.
How would your business idea contribute to making a step change in the clean energy market in Uganda?
5.
What output will the business idea deliver in terms of services or products?
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6.
What value will your business idea deliver 1) to your customers/clients; and, 2) to your organization?
1) to your customers/clients? What development impact will it have, especially for low-income households and
entrepreneurs, including women?
2) to your organization?
7.
How many new customers/clients will the business idea help you reach by the end of 2017? Briefly explain the
logic behind the proposed figure.
8.
1) Milestone activities for 2016-2017 2) Target market (e.g. consumer segment, geographic area)
1) Milestone activities for 2016-2017
2) Target market (e.g. consumer segment, geographic area)
9.
Partner Organisations (if any). What is their role in implementing this business idea?
10. Describe how the project will be managed and the involvement of senior leadership in the implementation.
11. What are the most important risks of the business idea? How will they be managed or mitigated?
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12. Expected start-date and duration of the project
Start date [dd/mm/yy]:
Duration:
13. Budget [USD]
At a minimum, the applicant should contribute at least 30% of the budget with no more than half of that amount as in-kind
contribution. In the case of consortium applications, cost-sharing can include resources from partner organizations in
addition to the lead applicant’s own resources. Only resources that are already secured should be included as a costsharing contribution. Preference could be given to applications with a higher percentage of cost-sharing.
Milestone activities
(Add more rows if needed)
1.
Amount (USD)
USD
Cost-sharing (USD)
CLEANSTART: USD
APPLICANT: USD (cash/in-kind)
2.
USD
CLEANSTART: USD
APPLICANT: USD (cash/in-kind)
3.
USD
CLEANSTART: USD
APPLICANT: USD (cash/in-kind)
Total budget
USD
CLEANSTART USD, %
APPLICANT (cash): USD, %
APPLICANT (in-kind): USD, %
14. Leverage potential (if any): Is there any potential for your business idea to secure other external funding? e.g.
investors, banks, donors
1) Names/types of funder:
2) Purpose of funding:
3) Amount: USD
15. Do you have at least one year of statutory financial accounts?
___ Yes
____ No
16. Do you have a certificate or other proof of business registration?
___ Yes
17. Contacts
1)
____ No
Person Responsible for Submission:
Name:
Title:
Address:
Email:
Telephone:
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2)
Lead Project Manager details, if different from above:
Name:
Title:
Address:
Email:
Telephone:
3)
Experience/Skills of Project Manager:
Executive Manager Signature:
Name:
…
Position:
Date: [dd/mm/yy]
4
…