“Connect

to Rebuild”
DAIC /Latitude Consultants Grant Assistance Program”

Please complete all questions on this form
Application Form
Call for Proposal: D/LC CtR 001
Publication Date: November 30th, 2017

st
Deadline: January 31 20184:30pm (Dominica Local Time)

IMPORTANT NOTICE

The “Connect to Rebuild” initiative is a collaboration between The Dominica Association of Industry
& Commerce (DAIC) and Latitude Consultants. The goal is to support Dominica’s rebuilding efforts
post Hurricane Maria by securing assistance for qualified small businesses. After identifying the
needs of small businesses we will seek to secure funding so that qualifying businesses are enabled to
offer the goods and services they are known for as quickly as possible.


Please read carefully before completing the application form.

An applicant may submit one (1) proposal/application form for this call.

I. Applications may be submitted in person to the DAIC office or via email to the daic@cwdom.dm address.
All applications must be submitted by the specified deadline date January 31st 2017 @ 4:30 pm (Dominica
time).

II. Applications submitted via specified email address (daic@cwdom.dm) with the required supporting
documents:

• Copy of Registration of Certification or copy of Certificate of Incorporation
• Completed DAIC Needs Assessment Form

III. Applications and supporting documents must only be submitted in Microsoft Word, Microsoft Excel or
Portable Document Format (PDF).

IV. Applications must contain text and may also include images or videos.

V. Applicants must ensure that they use the correct application form(s) for this CFP provided on DAIC’s
website and available at DAIC’s Office on 17 Castle Church Street. All other variations of the application
will be declared null and void.

VI. Applicants must ensure that Section 6, entitled “Applicant Declaration”, of the application form is signed
by the applicant, scanned and uploaded along with the completed application form. Application forms
which have not been duly signed will not be considered.

VII. Applicants will receive an email from DAIC confirming the date the application was received.

VIII. All information submitted by the applicant will be treated in a confidential manner.

IX. DAIC reserves the right to conduct due diligence on all applications received. This due diligence will be
conducted by DAIC and/or a Latitude Consultants to verify the accuracy of their proposal and/or
legitimacy of their business. Applications deemed to contain inaccurate/misleading information will be
rejected and those applicants will be barred from re-applying to DAIC programmes for a period of five
(5) years.

X. Failure to submit the required supporting documentation will result in the application being rejected.


1 PROFILE OF APPLICANT


COMPANY DETAILS
Name of Business
Physical Address
Postal Address if Different



Telephone Number

Fax Number
E-mail address
Website (if applicable)/Social Media Page
Date of Registration
Registration Number
Industry/Sector of Activity
Number of employees


CONTACT DETAILS
Title
First Name
Surname
Position
Telephone Number
Cellular/Mobile Number
Fax Number
E-mail Address


_____________________________________________________________________________________________
EMBRACING OPPORTUNITIES AND CHALLENGES
P.O. Box 85 * 17 Church Street * Roseau * Dominica * Tel: (767) 235 -1962
Email: daic@cwdom.dm Website: www.dominicachamber.org



2 NATURE OF BUSINESS


2.1 Give an overview of
your business
(include types of
products or services
offered, number of
employees, export
markets,
forecasted/future
areas for growth for
the business, etc.):

2.2 Tell us how your

business was
impacted by
Hurricane Maria and
why you believe the
“Connect to Rebuild”
program can help
you get your
business back on
track!




3 DESCRIPTION OF ACTION


How will this grant assistance help
you achieve your business
development plans?

_____________________________________________________________________________________________
EMBRACING OPPORTUNITIES AND CHALLENGES
P.O. Box 85 * 17 Church Street * Roseau * Dominica * Tel: (767) 235 -1962
Email: daic@cwdom.dm Website: www.dominicachamber.org


 Have you or are you considering
securing financial support with
another organisation/ program? IF
so which one (s)?

What are your top two (2)

equipment needs and state
prices? (Please attach invoice):

Please add any other information

that you feel may be relevant:
(continue on separate sheet if
necessary) :





4 SUPPORT DOCUMENTS REQUIRED


The following documents must be submitted as part of the application process:

1. Notarised1 copy of Registration of Certification or Notarised copy of Certificate of Incorporation

2. Quotes or Pro-forma invoices for the equipment being procured



5 THIRD PARTY GUARANTEE


Name:

Relationship:

Contact Number:

Signature:

1
Documents must be notarized by a Notary Public.
_____________________________________________________________________________________________
EMBRACING OPPORTUNITIES AND CHALLENGES
P.O. Box 85 * 17 Church Street * Roseau * Dominica * Tel: (767) 235 -1962
Email: daic@cwdom.dm Website: www.dominicachamber.org




6 APPLICANT DECLARATION

We the company hereby applies for a direct assistance grant to meet part of the cost of undertaking activities
to improve our rebuilding and enhance our competitiveness. We hereby declare that:
i. We are a private enterprise, registered in the Commonwealth of Dominica and majority owned by private
interests;
ii. The project for which we are applying for this grant can be reasonably expected to produce measurable
rehabilitation benefits to our company, well in excess of total consulting fees and expenses;
iii. If recommended to be awarded a grant, we accept the contractual obligations as laid down in the grant
contract;
iv. We do not use child labour in the normal production of our goods and services;
v. We conform with national health, labour, safety and environmental requirements;
vi. We agree to provide access to DAIC and/or a partnering Business Support Organisation in the applicant’s
country of domicile [Dominica] to verify the accuracy of the application and proposal and/or legitimacy of
the business. It is understood that if any application is deemed to contain inaccurate/misleading information
it will be rejected and that applicant will not be eligible to re-apply to DAIC’s programmes for a period of five
(5) years
vii. We will allow DAIC and Latitude Consultants to have access to and sight of all areas and records of our
operations relating to the proposed project for a period of up to three years after project completion;
viii. We accept that DAIC and Latitude Consultants will bear no responsibility for the project. The information
and statements contained in the accompanying Application for a Direct Assistance Grant are true, fair and
accurate to the best of our knowledge and it is understood that DAIC may withhold payment of the
assistance in the event of misrepresentation of any facts stated in this Application or in any subsequent
requests by ourselves for the payment of a Direct Assistance Grant;
ix. We agree to abide by the decisions of the DAIC and Latitude Consultants regarding the award or payment
of any Direct Assistance Grant requested by ourselves.
x. We understand that the DAIC and Latitude Consultants shall hold in confidence all information contained in
this Application and shall not at any time make any public disclosure regarding our enterprise, our activities
or the project under application without our prior written consent. This Application is made with the full
knowledge and acceptance of our Directors/Proprietors.

_____________________________________________________________________________________________
EMBRACING OPPORTUNITIES AND CHALLENGES
P.O. Box 85 * 17 Church Street * Roseau * Dominica * Tel: (767) 235 -1962
Email: daic@cwdom.dm Website: www.dominicachamber.org


I, ____________________________________________(insert name and title), am duly authorised to file and
sign this application on behalf of _________________________________________ (insert name of company).

Name
Position
Signature Date

7 CHECKLIST


Before submitting your proposal, please check that each of the following components is satisfied and
completed.
To be
completed by
Applicant
1. Completed Application Form.
2. Applicant Declaration Form signed and dated
3. Proof of Registration or Incorporation
4. DAIC Needs Assessment Form completed
5. The budget is presented and expressed in ECD
6. The requested contribution is equal to or less than
$1,500.00 USD (the maximum allowed)

_____________________________________________________________________________________________
EMBRACING OPPORTUNITIES AND CHALLENGES
P.O. Box 85 * 17 Church Street * Roseau * Dominica * Tel: (767) 235 -1962
Email: daic@cwdom.dm Website: www.dominicachamber.org