APPLICATION FORM

Self-Employment Support measure (SESM)

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INFORMATION CONCERNING THE PROMOTER(S)
 
Number of promoters in the project : *
Promoter 1 : *
First name : * Last name : *
Address : * City : *
Postal code : * Phone(home): *
Mobile phone : Email : (aa@bb.xyz) *
Date of birth : Day Month Year *
Marital status : * Language : Other: *
Status in Canada : * Current situation :
Country of origin : Last schooling diploma completed : *
Gender : *

NOTE : For each question, you have a maximum of 200 characters.

Promoter's experiences connected to the project :
You have characters left.
Promoter's education connected to the project :
You have characters left.
Business knowledge of the promoter :
You have characters left.
Have you ever filed bankruptcy ?
If yes, have you been released ?  Since when ? (yyyy/mm/dd) 

PERSONAL STATEMENT *
 
ASSETS Promoter 1 Promoter 2 Promoter 3
Cash in hand
Fixed term deposits
Guaranteed Income Certificates
Mutual funds and segregated funds
Stocks/Bonds
R.R.S.P.
Real estate
Car (Buy-back value)
Furniture (Buy-back value)
Others
TOTAL :
LIABILITIES Promoter 1 Promoter 2 Promoter 3
Credit cards
Line of credit
Personal loan
Mortgage loan
Student loan
Endorsements (eventual debts)
Others
TOTAL :
VALUE : (diff. assets/liabilities)

PROJECT INFORMATION *
 
Business location
Address : If a current business  Postal Code : If a current business 
Montreal borough :
Name of business (if already determined) :
When did you start up your business or when do you plan starting it up ? : (format: yyyy/mm/dd)
 
Projet description (Products and/or services) :
You have characters left.
 
Who will be your main customers (individuals or companies) ? (Describe their profile) You have characters left.
 
Who are your main competitors and how many are there in your field (strenghts and weaknesses) ? You have characters left.
 
How is your company different apart from the competition ?
You have characters left.
 
Potential of your market :
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Provide an estimate of your annual sales figure for the 1st year :

PROJECT FINANCING *
 
EVALUATION OF START-UP NEEDS :
Capital assets : I own + I must buy = Starting cost
Computer equipment (hardware)
Software
Vehicules (if required for project)
Equipment (fax, photocopier,production, other)
Office furniture
Licenses, permits, patents
Others, specify :
Starting inventory : (for a shop or a factory project)
Start-up expenses :
Installation (telephone, electricity)
Lay-out of premises
Required deposits (public services, lessor, etc.)
Legal and professional fees
Promotional supplies
Others, specify :

Sous-total (1)

MONTHLY OPERATING EXPENSES (expenses of the first months of activity, before regular sales)
Travel and representation expenses x 3 months
Salaries of other employees x 3 months 
Rent x 3 months
Publicity x 3 months 
Delivery costs x 3 months
Office expenses x 3 months 
Telephone, Internet x 3 months 
Electricity x 3 months
Insurance (office, vehicule) x 3 months 
Taxes and permits (occupation, posting, business) x 3 months 
Others, specify : x 3 months 

SUBTOTAL (2) :

TOTAL AMOUNT (1+2) :

(A)
FINANCING SOURCES
Investment of the promoter in the project :

Cash investment ($) :

Equipement:
TOTAL : (B)
External financing to obtain :

Subtract TOTAL AMOUNT (A-B) =

Will you need funding or a grant ?
 
WHAT FINANCING SOURCES DO YOU PLAN TO SEEK OUT ?

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ADDITIONAL INFORMATION *
Through what source did you find out about SAJE accompagnateur d'entrepreneurs ?

I authorize you to communicate with me by email :

I want to subscribe to SAJE's Entrepreneur Directory :

 
ACKNOLEDGEMENT OF PROMOTER(S) *

I, , (appliquant), certify that the information contained here in and in documents hereby annexed are, to my knowledge, complete and truthful in their entirely. Any incorrect information, false declaration and/or omission will immediately lead to the definitive rejection of my request.

Documents handed in by the promoter(s) remain the property of SAJE  who warrants their confidentiality. However, the promoter(s) authorize SAJE to exchange with other people who are affected and involved in the decisional process of his/her/their file, and with his/her/their financial institution, all information or documents necessary to the evaluation of the present request. The promoter(s) disclaim the members of the selection committee and the coordinator of all responsibility or eventual lawsuits that may be incurred by their decision or recommendation.

Acceptation of promoter 1 : Date : (format: yyyy/mm/dd) 

Acceptation of promoter 2 : Date : (format: yyyy/mm/dd) 

Acceptation of promoter 3 : Date : (format: yyyy/mm/dd) 

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