APPLICATION FORM Certificate Program in Management and Innovation for Agribusiness Entrepreneurs PROGRAMME OVERVIEW The Certificate Program in Management and Innovation for Agribusiness Entrepreneurs is aimed at improving the management and leadership capacity of small scale agribusiness entrepreneurs through training to improve the quality and increase the productivity of the agricultural sector and thereby contribute to food security in Kenya. The training will lead to the award of a Certificate in Management and Innovation for Agribusiness Entrepreneurs. The training outcomes are to provide analytical tools, market-oriented skills and information to increase the quality and productivity of the agricultural sector and contribute to food security. USIU has partnered with Michigan State University (MSU) and Global Business Schools Network (GBSN) to support key activities. The USIU Agribusiness Program has been operating since 2011, with the support of the Bill & Melinda Gates Foundation. Thus far, three groups of Agribusiness entrepreneurs drawn from all over the country have successfully completed the program. Participants who have benefited from the program are different actors of the agricultural value chain. The program has now graduated into a self-funded program with flexible modes of delivery as shown in the table below: Mode Days of Attendance Time Total Duration Venue Regular 5 days per month 8:30am 5pm 4 months USIU Flexible 3 days a week per month 8:30am 5pm 6 months USIU Evening 2 days per week 5:30pm 8:30pm 6 months TBA 1
ELIGIBILITY 1. Small scale agribusiness entrepreneurs or those intending to start new agribusiness enterprises. 2. Experienced entrepreneurs running/managing an agribusiness. 3. The business must be actively seeking for opportunities in the agricultural supply chain. 4. The applicant should demonstrate entrepreneurial ability and passion to grow the business. TARGET GROUP Leaders of farmer organizations Owner/managers of small and medium-sized businesses involved in agricultural product processing (e.g. Juice processing, dairy products processing) Agricultural produce exporters, processors and aggregators. Distributors of farm inputs (e.g. stockists) producers or suppliers of agricultural inputs Crop or livestock production and other eligible players in the agricultural value chain. NGO staff supporting agribusiness SMEs In addition, all applicants must: Submit their applications no later than 20 th December, 2013 Be prepared, if shortlisted for the program, to attend a 20-minute in-person interview at USIU REQUIRED DOCUMENTS Completed application form with 2 passport size photos Copy of education certificates 500 word essay on the status of the business A letter of recommendation from a financial institution or trade association Please note: 1. Completing this application form does not guarantee admission to the Agribusiness Certificate Program. 2. Exceptions to the eligibility criteria may be considered in cases where the owner and/or business has substantial opportunities for growth and would benefit significantly from the program. 3. All personal and financial information provided in this application will remain strictly confidential and used solely for the purpose of determining program eligibility and support. 2
PAYMENT DETAILS Commercial Bank of Africa Ltd. Upper Hill Branch, Mara & Ragati Roads P.O. Box 30437-00100, Nairobi, Kenya Tel: +254(0)20 288 4000/273 4555 Fax: +254(0)20 273 4616 Kshs Account number: 6438840014 Account name: USIU or U.S. International University Swift Code: CBAFKENX Routing number: 021000021 2. The Co-Operative Bank of Kenya Ltd. Main Branch, Co-Op House, Haile Selassie Avenue, P.O. Box 67881-00200, Nairobi, Kenya Tel: +254(0)20 327 6000 Fax: +254(0)20 327 6526 Kshs Account number: 01120002134100 Account name: USIU or U.S. International University 3. Standard Chartered Bank Kenya Ltd. Kenyatta Avenue Branch, P.O. Box 40310-00100, Nairobi, Kenya Tel: +254(0)20 329 4000 Fax: +254(0)20 341 076 Kshs Account number: 0104023439700 Account name: USIU or U.S. International University 4. Payments by electronic cards JCB card MasterCard Visa card Visa electronic card (debit card) 3
SUBMISSION INSTRUCTIONS There are several ways to submit your completed application: By email: to agribusiness@usiu.ac.ke Copy: kmusikoyo@usiu.ac.ke NOTE: Applications submitted via email require that the signed signature page and required documents be scanned and submitted by email or faxed or mailed separately. By mail send to: The Program Manager, USIU Agribusiness Project, Chandaria School of Business, United States International University, P.O. Box 14634, 00800 Nairobi. 4
PERSONAL INFO 1 Name of Applicant Mr./Ms. First Name Other Names 2 Nationality 3 Type of Identification 4 National I.D. number 5 Passport Number 6 Are you a Permanent Kenyan resident or Citizen? Yes No 7 Applicants' Contact Details Mailing Address Business Location Phone (Landline) Phone (Mobile) Email 8 Number of Employees (including Yourslef if you work full time at the business) Permanent (Works over 35 hours a week): Temporary ( Not hired, works for a limited period of time): 9 Personal Information Date of Birth (mm/dd/yy) Marital Status 10 Next of ) kin or guardian (Contact in case of an emergency) Name Current mailing address Phone (Landline) Phone (Mobile) 11 Number of household members: 12 Number of income earners in the household 13 Number of individuals (inside and outside your household ) who depend on your income 5
ACADEMIC ACHIEVEMENT Please list all the schools and colleges/universities attended in the following section Name of School / College / University City/ Country Years (from to) Area of Study Name of Certificate awarded OTHER BUSINESS TRAINING PROGRAMS Please list all the other short trainings attended in the following section Name of Training Institution Country Duration (Hours/days) Certificate Awarded How did you learn about this agribusiness training? i) Business association attended, please specify: ii) A local farmers co-operative society, please specify: iii) Friend iv)newspaper v) T.V. /Radio vi) Trade/business vii) Internet viii) USIU Website: x) Ministry of Agriculture xi) USIU staff xii) USIU Brochures/ Course Information Material viii) Other (specify) 6
WORK EXPERIENCE List the organizations/businesses you have worked for and the position occupied for the last ten years starting with the current organization/agribusiness. Name of Organization Position Held Date 1. 2. 3. BUSINESS OWNERSHIP How many agribusinesses/businesses do you own/co-own currently? Please list them below; S. no. Name of business owned or co-owned How long have you owned or co-owned the business? 1 2 3 4 Name of Current Business Year established Starting Capital (Kshs) Starting capital sources: Business registration number Business sector/industry Brief description of business/industry Brief description of business products and services offered Financial status of current business Please answer the questions below as accurately as possible. If you are unsure of an answer please estimate and state that the answer provided is an estimate. What is the average yearly gross turnover of your business? Ksh. What is the average yearly profit generated by your business? 7
What was your business s gross revenue last month? What was your company s revenue last financial year? Do you hold a business bank account? YES NO BUSINESS INCOME AND EXPENSES Please list below your business yearly expenses in Kenya Shillings (Ksh). Rent for business premises/farm Healthcare Transportation/Car Employee Salaries Utilities Other (please specify) PERSONAL FINANCIAL STATUS Please answer the questions below as accurately as possible. If you are unsure of an answer please estimate and state that the answer provided is an estimate. Personal Income Please list below your yearly sources of income. Include income contributed by spouse, parents, relatives, employment, businesses, etc. Income Amount #1 Source #1 Income Amount #2 Source #2 Personal Expenses Please list below your yearly expenses. Housing Healthcare Transportation/Car Food Children s school fee Other (please specify) ATTESTATION I confirm that the information provided above is accurate to the best of my knowledge. I understand that if I have deliberately provided false information, I will have to forfeit the agribusiness certificate program scholarship if one is awarded to me. Print Full Name Position Signature Date 8
Business Statement 9