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PLEASE COMPLETE THIS FORM IN BLOCK LETTERS. All blanks must be completed. Use “N/A” if blank is not
applicable. If more than one borrower attach details of other borrowers on separate sheet of paper
BORROWER’S PERSONAL DETAILS
Surname First Name Middle Name
In the event that are not successful can Family Bank/ Kenya ICT Board share your plan with partners who
are interested in providing funding? No Yes
DECLARATION
I/We declare that all the information given herein and attached is true to the best of my/our knowledge
and belief: I/We further authorize Family Bank Ltd. to verify the information given herein and make
reference from any person(s)/institution(s) named herein or on the attached documents
I/We also authorize you to obtain any information you may require relating to this application from my
employers, if any and from any other source to which you may apply, each source hereby authorized by
me/us to provide you with such information.
I/We undertake to notify Family Bank Ltd immediately of any situation which materially changes the
representation of this application. I/We hereby authorize Family Bank Ltd. to disclose any and all
information in respect of my account to Kenya ICT Board, for as long as my/our debt to Family bank is
outstanding.
I/We confirm that I/We am/are in good health and accept and agree to be bound by the terms and
conditions as will be contained in the Pasha loan Terms and conditions
NAME SIGNATURE DATE dd/mm/year
Name: _______________________________________________Manager
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SECTION I: BUSINESS DESCRIPTION
Business Name
Type of Business
Description Tick as appropriate:
(a) new business (b) takeover (c) expansion
Other (please specify)
Date of Commencement (When business started or proposed date for starting it)
MM/DD/YYYY
Physical Location Town/Shopping Centre
Street/Road
Name of Premises
Constituency
County
Accessibility (tick as appropriate)
(a) Road (b) Rail (c) Water (d) Air
Other (please specify)
Advantages derived from
the location of the
business
Nearest landmark
Postal Address
Telephone Numbers
Fax Numbers
Email Address
Form of Business Tick as appropriate:
Ownership (a) Sole (b) Partnership (c) Limited Liability
Proprietor Company
(d) Other – specify:
Brief History of the
Business and its Current
Status
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targets)
3 Growth Objectives
4 Social Objectives
(Value and
contributions to
the nearby
community)
2.
Others
Total
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Telephone
Transport
Stationary
Advertising
Repairs & Maintenance
Taxes
Insurance
Bank Charges
Legal Fees
Licenses & Permits
Any Other Expenses
Total
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6.7 Professional and Support Services
Services Service Provider & Monthly Fees Annual Cost
Contact (KES) (KES)
Legal Services
Banking Services
Accounting Services
Technical Support (Maintenance)
Quality Controls
Total
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SECTION VII: FINANCIAL PLAN
7.1 Assumptions
The proposed business proprietor(s) have put in place the following assumptions:
1. That the security situation in the country will continue to improve and hence disturbances caused by
insecurity will not be experienced.
2. The rate of inflation will not escalate so as to cause price disturbance, thus the given prices will hold
for five years.
3. The projected human resource requirements will be obtained at the given costs.
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7.2 Pre-operational Costs (costs before start-up)- to be filled by start ups ONLY
Name of Pasha
Pre-Operational Costs
Item Cost (KES)
Land, Building & Construction – Lease
Renovations
Equipment
Electricity
Security, e.g., watchmen, alarm system
Water
Telephone & Postage
Survey Fees
Legal Fees
Registration Fees
Licenses & Permits
Patents & Copyrights
Rent
Furniture, Fixtures & Fittings
Installation, e.g., networks, switches
Stationary
Stock of retail, material goods
Reproduction of documents
Wages & Salaries
Staff Training
Bank Charges
Transport
Insurance
Advertising
Other Expenses
Total
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7.3 Working Capital- to be filled
Name of Pasha
Working Capital
Amount (KES)
Item Year 1 Year 2 Year 3
A. Current Assets
Prepayments (deposits)
Cash at Bank
Cash in Hand
Total
B. Current Liabilities
Short-term Loan
Bills Payable
Creditors
Total
A – B = Working Capital Total
Name of Pasha
Revenue Projections
Items ( for Examples- Stationery, ICT Units Unit price Quantity Amount (KES)
items, Photocopying, Scanning, (pieces) sold Year 1 Year 2
Training, Mobile air-time sales etc)
Totals
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SECTION 8: Current Financial Status
FINANCIAL DETAILS
4.1 Bank Accounts: kindly provide details of all bank accounts held (Please provide 6 months Account
statements for all accounts listed)
ACCOUNT TYPE BANK BRANCH ACCOUNT NUMBER
Credit History
Do you have any credit facility from any other bank or institutions? Yes No
If the answer is yes please provide details on each and provide copies of repayment receipts/ or loan
statements for the last 3 payments.
1 2 3 4
Type of Loan
Name of Lender
Date Loan Paid-off/ to be Paid -off
Loan Amount Disbursed
Amount Outstanding
Monthly Instalment Amount
Number of payments made on
time
Number of payments paid late
Security Held
Do you plan on borrowing any money from any organization during the tenure of the loan been currently
applied for? Yes No If yes, please provide terms and purpose.
Are you a guarantor for any other loans not listed above? Yes / No
If yes, please provide full details.
Kindly list all significant personal assets owned and any liabilities against them,
SECTION 9: REFERENCES
Please provide the details of 3 (three) non-family referees below:
Full Names: ___________________________________________________________________________
Relationship:________________________________________ Occupation: ________________________
P.O. Box ___________________Code______________ Town: _________________________
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Telephone Numbers
Mobile: ______________________/_____________________/_____________________
Office: ______________________/_____________________Residential:_____________________
Email address: Persoanal:_____________________________Office:______________________________
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