Norfolk District Business Development Corporation
Box 732, 4077 Highway #3 East
Simcoe, ON N3Y 4T2
Tel: (519) 428-2323 Fax: (519) 428-0074
SELF EMPLOYMENT BENEFITS PROGRAM
BUSINESS CONCEPT PROPOSAL
SEB APPLICATION FORM
Proposed Business Name:
Business Concept: __________________________________________________
Blank electronic template available at: http://www.ndbdc.com/seminars
All information disclosed in this proposal will remain confidential and will be used only for the purposes of evaluating the
viability of the business idea and the suitability of the applicant for the Self-Employment Benefit Program.
1. Briefly describe the product or service your business will provide.
2a. What skills and experience do you have that will help you operate this business?
2b. Identify the reasons for starting this business. Is self employment your best alternative at the present time?
If so indicate your reasons.
3a. Is there any specific skill or business training NDBDC could conduct that you feel would improve your
ability to operate the business? (i.e. basic computer skills, bookkeeping, Internet, networking, marketing,
advertising, time management, sales and cold calling skills etc.)
3b. Why is the SEB allowance needed? Please be specific.
4. Which competitors are providing an identical or similar product/service?
Competitor Name Location Price Level
What price level will your product/service be?
5. Describe how your product/service is unique and what you feel is your competitive advantage.
6. Who is your primary target market (intended customers)? What do you expect the size of the market to be?
7. Why do you think there is a need/demand for your product/service? What market research have you done
to date? What sort of response/feedback have you received from potential customers? How does this support
your decision to start this business?
8. How will you promote your product/service and what will be your promotional message to potential
9. What do you estimate are your total start up costs and where will the money come from?
10. Are there any environmental concerns associated with your business operations, and if so what are they?
Detail what you will do to comply with all applicable regulations.
11. Summarize why you think this business concept will succeed.
Home: (___) _____________ Business Telephone: ( ___ ) ____________
Mobile: (___) _____________ Fax: ( ___ ) ____________
Marital Status: ____________________ Number of Dependants (excl. spouse): _____________
Municipal Ward #: _________________ Date of Birth: DD/MM/YY _____ / _____ / ________
BUSINESS CONTACTS: (optional)
Bank: ________________________________________ Contact: _____________________________
Legal Firm: ____________________________________ Contact: _____________________________
Accounting Firm: _______________________________ Contact: _____________________________
Start-up Funds required: Source of Funds:
Rent / lease / land Applicant Cash
Building / renovations Bank
Working Capital In kind:
PERSONAL FINANCIAL STATEMENT:
Name (first/middle/last) SIN (optional) Date of Birth (dd/mm/yy)
Street Address / R.R.# /P.O. BOX Town Postal Code Telephone Number
Name of Spouse SIN (optional) Date of Birth (dd/mm/yy)
Spouse’s Employer Employer Address Telephone Number
CASH & DEPOSIT ACCOUNTS $ BANK LOANS $
STOCKS / BONDS / RRSP’S $ CREDIT CARDS $
LIFE INSURANCE: NET CSV $ LOANS AGAINST LIFE INSURANCE $
REAL ESTATE $ MORTGAGES $
OTHER INVESTMENTS $ UNPAID INCOME TAX $
VEHICLES $ UNPAID PROPERTY TAX $
OTHER ASSETS $ OTHER LIABILITIES $
(A) TOTAL ASSETS $ (B) TOTAL LIABILITIES $
NET WORTH (A) - (B) $
ANNUAL INCOME (for next 12 months) ANNUAL EXPENDITURES (for next 12 months)
SELF SPOUSE RENT / MORTGAGE PAYMENTS $
GROSS NET GROSS NET
(After Ded) (After Ded) LOAN PAYMENTS $
SALARY, WAGES - - HEAT / HYDRO / TELEPHONE $
DIVIDENDS, INTEREST PROPERTY / CONTENTS INSURANCE $
RENTAL INCOME LIFE INSURANCE $
BUSINESS INCOME PROPERTY TAXES $
SEB ALLOWANCE 16,920 16,000 FOOD / CLOTHING $
OTHER INCOME VEHICLE OPERATION & INSURANCE $
RECREATION & EDUCATION $
TOTAL INDIVIDUAL MISCELLANEOUS $
TOTAL HOUSEHOLD INCOME NET $ TOTAL ANNUAL EXPENDITURES $
Additional Information: 1. Are you liable as a co-signer or guarantor? Yes No
2. Are there or has there ever been any lawsuits or judgments against you? Yes No
3. Are you now or have you ever been bankrupt? Yes No
4. Are you in default of any amount owing to the federal government? Yes No
1. I/we hereby certify that the information given in this personal financial statement is true, accurate and complete in all instances and
accurately reflects my financial situation as at the statement date.
2. I/we fully understand that such information shall be used to determine my credit worth. I authorize the NDBDC to obtain personal credit
information about me from any source. By executing this statement, I acknowledge as notice in writing, the NDBDC’s intent to obtain this
information and I authorize each source to provide this information to the NDBDC.
3. I/we understand that the NDBDC will handle my personal information in strict confidence in accordance with federal privacy law as set
Signature: ____________________________________ Signature: ____________________________________ Date: _______________
I hereby certify that all the information given by me in this Business Concept Proposal and SEB Application
is accurate, complete, and true. I understand that any false information given may result in the denial of this
application and/or immediate dismissal from the SEB program.
I further understand that:
Ontario Ministry of Training, Colleges, and Universities (MTCU) has final approval of my application
to the SEB Program.
I must work full-time (minimum 35 hours/week) at this proposed business venture
the period of financial support is 40 calendar weeks from the commencement date and that the period
of business advisory assistance is 52 weeks from the commencement date
I am solely responsible for the undertaking of this proposed business venture. I consent to the Norfolk
District Business Development Corporation or its agents making any inquiries of such persons, firms, or
corporation as it deems necessary in order to adequately assess the business venture and to confirm my
eligibility for benefits under the Employment Insurance Act.
I, the undersigned, by executing this statement, consent to my personal information being collected, used,
retained, and disclosed by the NDBDC for purposes of assessing eligibility for the NDBDC services,
communicating future NDBDC services, monitoring the progress of the business, and meeting legal and
regulatory requirements. I acknowledge receipt of the NDBDC’s Privacy Statement (see below) and hereby
consent to the use of my personal information as set out above.
The Norfolk District Business Development Corporation (NDBDC) respects the privacy of its clients. In doing business with the NDBDC, you, the client, provide
privacy. It was developed to comply with Canada's Personal Information Protection and Electronic Documents Act ("PIPEDA"). PIPEDA sets out rules for the collection,
use and disclosure of a client's or customer's personal information, as well as safeguarding that information in the course of commercial activity as defined in the
WHAT IS "PERSONAL INFORMATION" "Personal Information" means any information that is identifiable to an individual, including name, address, telephone number,
Social Insurance Number, and date of birth. It also includes, but is not limited to, other information relating to identity, such as, nationality, gender, marital status, financial
information and credit history.
PURPOSES FOR PERSONAL INFORMATION The NDBDC collects only that personal information required to assess a prospective applicant's eligibility for services of
the NDBDC as well as to report to Industry Canada, the federal department that supports the objectives of the NDBDC.
CONSENT At the time of completing an application for consideration of a service at the NDBDC, the express, written consent of the individual applicant will be sought for
An applicant may choose not to provide some or all of the personal information requested, but if the NDBDC is unable to validate the information provided, the application
may be turned down.
ACCURACY The NDBDC endeavors to ensure that all personal information in active files is accurate, current and complete. An individual who wishes to review or verify
what personal information is held by the NDBDC, may do so by making a request, in writing to the NDBDC's Chief Privacy Officer. Upon verification of the individual's
identity, the Chief Privacy Office will provide a written report within 60 days. Information contained in closed files is not updated.
SAFEGUARDS The NDBDC utilizes a number of physical, organizational and technological measures to safeguard personal information from unauthorized access or
INVESTIGATING COMPLAINTS Any concern or issue about the NDBDC personal information handling practices may be made, in writing, to the Chief Privacy Officer.
Upon verification of the individual's identity, the Chief Privacy Officer will act promptly to investigate the complaint and provide a written report to the individual.
If the individual is dissatisfied with the report provided by the Chief Privacy Officer, or feels that the corrective action taken by the NDBDC is insufficient, the individual
available at our office or on our website (www.ndbdc.com).
and will apply to all personal information collected from the date of the posting of the revised documents.
For additional information, please contact the NDBDC office in Simcoe at 519-428-2323