Company Name*

Incorporation Number*

BOT Licence Number*

TIN Number*

Business Licence Number*

Branch Locations

HQ Location*

1st Branch Location

2nd Branch Location

3rd Branch Location

Contact Information

Official Company Contacts* (Phone/Email)

CEO Name and Contacts*

Program Coordinator Name and Contacts*

Compliance Declaration

Are you ready to register for CRB?* YesNoIn Progress

Are you ready to use CYDM recommended microfinance software?* YesNoNeed Training

Are you ready for compliance with BOT, TRA and licencing authorities?* YesNoIn Progress

How much seed capital are you willing to offer? (Minimum TZS 10,000,000)*

Do you have a loan policy ready?* YesNoNeed Assistance

Final Declaration

I declare that all the above information is true and I will comply with CYDM policies and procedures accordingly

Authorized Signatory Name*

Signature (Type Full Name)*

Date