Capital Raise Assessment Form

A. Company & Capital Requirement Details

Entrepreneur & Company Details

First Name

Last Name

E-mail address

Phone Number

Business Name

Business Location

Nature of business (State products and/or services)

Sector of business

Please specify

Number of staff (Please type 0 if not applicable).

	No. of Male	No. of Female
Fulltime staff
Part-time staff

Number of branches

Business Registration

Type of incorporation.

Limited LiabilityPartnershipSole ProprietorshipNGO

Details of directors (including shareholding).

	Name of Director	Percentage Shareholding
Director 1
Director 2
Director 3
Director 4
Director 5

Years in operation

Year of incorporation

TIN Number

Name of Bankers

Name of Auditors

Name of Solicitors

Financial Snapshot

Please provide annual revenues for the past 3 years, beginning from the previous year but excluding the current year (eg. Year 1 - 2020, Year 2 - 2019, Year 3 - 2018). (Put 0 if not applicable)

	Year 1	Year 2	Year 3
3-Year Revenues

Profit/ Loss %

Total Assets (Ghs)

Total Liabilities (Ghs)

Capital Raise Requirements

Amount required (Ghs)

Amount raised (Ghs) ( Put 0 if no money has been raised)

Type of Capital required

EquityQuasi - DebtDebt

How much equity (%) are you prepared to give up?

Use of Funds (Ghs)

B. Business Assessment Questionnaire

Key Management Team

	Educational Background	Years of Experience	Roles & Responsibilities
CEO/Lead Entrepreneur
Operations Manager
Finance Manager
Marketing Manager
HR Manager
Chief Technology Officer
Business Development Manager

Other key management roles not stated above.

Does the founder work full time on the business?.

YesNo

Products and Services

What is your leading product or service?

Market Size

Describe your target market and the size of that market

What is your current share of this market and what are your future projections?

Competition

Who are your competitors and what gives you an advantage over them?

What barriers prevent more competitors from entering your market?

Growth Strategy

What are your growth plans for the next 3 years?

Key Business Drivers

Please describe your revenue and cost drivers

Are these factors within the control of your business?

Yes No

Key Assets

List any key assets in the name of the company with details of cost(s) and year(s) of acquisition. (eg. 1. Vehicle - Ghs20,000.00 - 2019)

Do you need to acquire additional assets?

YesNo

Major Customers

Who are your major customers? (Please list)

How many are repeat customers?

C. Key Information Availability Checklist

Business Operations

Remarks

Please share link to documents.

Kindly upload the following documents to Google drive (audited financial statements, updated business plan, pitch deck, 3-year financial projections, invoices to support capital expenditure and business registration document) if you have them and paste the google drive link in the space below.

	Yes	No
Business plan
Operational plan
Resume/ Profile of business owner
Regulatory approvals and licenses (if applicable)
Breakdown of investments to date

	Yes	No
Certificate of Incorporation
Form 3
Form 4

	Yes	No
Balance sheet
Income statement
Cashflow statement

	Yes	No
Accounting Software
12-month bookkeeping records
Tax Clearance Certificate for previous year

	Yes	No
2022
2023
2024

	Yes	No
2021
2020
2019