Shuraako Pre_Assessment Questionnaire

Shuraako Pre-Assessment Questionnaire

<Business Name>
<Date>

DIRECTIONS: Completing and submitting the Pre-Assessment Questionnaire is a mandatory first step in Shuraako’s application process.
Ensure that all questions are answered according to the guidelines stated throughout this form. The submission must be in English.

Once completed, submit the Pre-Assessment Questionnaire (and accompanying documentation) to the appropriate regional
representative: Ms. Sahra Hassan (shassan@shuraako.org) responsible for Somaliland, or Mr. Abdirahman Mohamud
(amohamud@shuraako.org) responsible for Puntland, and Mr. Mohamed Abdi Hashi (mhashi@shuraako.org) responsible for South
Central Somalia. If you have not received acknowledgement of submission within 10 business days, email Shuraako immediately
(info@shuraako.org). If you have any questions pertaining to the Pre-Assessment Questionnaire contact your regional representative.
Once received, Shuraako will review and identify candidates that are most appropriate for investment.
 Shuraako Pre_Assessment Questionnaire

1. Contact Details
Business Name:
Name of Main Business Owner:
Tel:
Email Address 1:
Email Address 2:
Age Range: 15-35 36 and above
Gender: Male Female ✘
Are you Diaspora?
If Yes which Country: ________________________________
Yes No
What was your last known address? ____________________
___________________________________________________

Do you have other nationalities?

Yes No
If yes, please provide copies of all your IDs.
Does anyone in the business have Business Owners Yes No __________________
any criminal convictions?
Key Management Yes No ___________________

How did you hear about Shuraako? Check the relevant boxes.
Shuraako event
Shuraako staff
Shuraako website
Shuraako Client
Word of mouth
Other: Please explain ____________________________

2. Business Location
Check the appropriate box.
South Central
Puntland
Somaliland

3. Business Growth Stage

Check the appropriate box.
Startup: A new business created from scratch (or one that did not previously exist).
Existing Business: A business already in existence but seeking investment for expansion.
Year Business was founded:
New Project within an Existing Business: A new enterprise/project that is launching from an
already existing business.

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 Shuraako Pre_Assessment Questionnaire

4. Business/Project Details
Size of Investment Request ($)
Owner Cash Contribution ($)
Sector:
Is the business registered?
Years of operation:
What was your last year Gross Revenues: $.................Profit/loss $…………….
What is the number of your current employees?

5. Business Profile Summary

Provide a brief business profile. Please address the following 3 points:
a. How has your business started (brief history)?
b. How many people do you currently employ?
c. Describe the products and/or services your business provides.
d. Why do you need this investment?
e. How will the assets purchased with the investment increase revenue and/or profit?

This field should not exceed 1,000 words

a. .

b. .

c. .

d. .

e. .

f. Have you received funding from a bank or other investors in the past?

Yes
No

6. Assets Needed
Specify the items you will purchase with the investment and with the owner cash contribution. Add
rows if necessary.

No. Items Cost / Amount (USD)

1
2
3
4
5
Total

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 Shuraako Pre_Assessment Questionnaire

7. Collateral
List assets you or the business owns that you will use as security for this loan such as property
and land (assets which are not currently held for another loan, i.e., from local banks).

No. Item Value (USD)

1
2
3
4
5
Total

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