APPLICATION FORM FOR THE UNCTAD - EMPRETEC TRAINING WORKSHOP

Name: WIRDAWATY USMAN

ID N.: 7571056410660001 Date: 29/10/1966

Dear Entrepreneur ,

Thank you for your interest in the UNCTAD - Empretec Programme, one of
the leading programmes for entrepreneurship development in the world! The
following questions will be used to register your profile in our database and to get
to know you better. Please, make sure you answer ALL QUESTIONS present in the
following questionnaire. The FULL COMPLETION of the following questionnaire is
a PRECONDITION for the next step (the individual interview). Your answers will be
kept confidential and restrict access will be given only to the interviewer.

UNCTAD - Empretec Programme

1. Contact details:

Home address: Perum graha nirwana no 4 kayu ZIP code: 96181

bulan Limboto kab Gorontalo
State: Indonesia City: Gorontalo
Phone: - Mobile: 081244651399
E-mail: wirdawatyusman5@gmail.com
Core business: Kuliner
Business address: Perum graha nirwana no 4 kayu ZIP code: 96181
bulan Limboto kab Gorontalo
State: Indonesia City: Gorontalo
Business Phone: 081244651399 Fax: -
Website: https://www.facebook.com/ukm.nirwana?mibextid=rS40aB7S9Ucbxw6v

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2. Sex: 3. Date of birth:

( ) Male ( ✓ ) Female 29/10/1966

4. Family status:

( ) Single ( ✓ ) Married ( ) Divorced ( ) Widowed

Nº of children: 1

Nº of people living at your residence, including yourself: 2

5. Level of education (mark the appropriate response):

( ✓ ) Primary school

( ✓ ) High school / Secondary school.

( ) Technical school? ( ) No ( ) Yes. Which area? __________

( ) University degree. Course? ________________

( ) Post / education / Masters / PhD

6. How did you find out about Empretec?

( ) Empretec home page

( ✓ ) Newspaper add, magazine, out-door, Internet, radio or television

( ) A phone call,e-mail or letter from UNCTAD or UNDP

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( ) A friend who completed the Empretec programme

( ) Event/Exhibition

( ) Other. Which one?

________________________________________________

7. You decided to participate on Empretec because...

( ) I want business/entrepreneurship training

( ) I want to start a business

( ) I want to improve my current business

( ✓ ) I want to expand or innovate my current business

( ) Other reason. Which one ?

__________________________________________

8. Your current professional occupation is...

( ) I am not currently working and never held a paid job

( ) I am not currently working, but held paid work previously

( ) I am currently employed (temporary contract)

( ) I am currently employed (permanent contract)

( ) I am self-employed (freelancer, consultant)

( ) I have an informal business (meaning, without a business ID)

( ✓ ) I have a formal business (meaning, with a company ID)

9. Still about your current professional situation...

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( ) I do not have my own business and do not intend to start one or engage in
one

( ) I do not have my own business, but I intend to start or engage in one

( ) I started or take part of a business established less than 6 months ago

( ) I started or take part of a business established 6 months ago (or more), but
does not generate profit yet

( ✓ ) I started a business or take part of one established 6 months ago (or more)
which already generates profits

10. Your current individual average monthly income is...

( ) Less than 3 minimum salaries

( ) Equal or more than but less than 6 minimum salaries

( ) Equal or more than 6 but less than 9 minimum salaries

( ✓ ) Equal or more than 9 but less than 12 minimum salaries

( ) Equal or more than 12 but less than 15 minimum salaries

( ) Equal or more than 15 minimum salaries

11. Your average monthly family income is...

( ) Less than 3 minimum salaries

( ) Equal or more than but less than 6 minimum salaries

( ) Equal or more than 6 but less than 9 minimum salaries

( ✓ ) Equal or more than 9 but less than 12 minimum salaries

( ) Equal or more than 12 but less than 15 minimum salaries

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( ) Equal or more than 15 minimum salaries

12. Did your father or mother ever own their own business?

( ✓ ) No

( ) Yes. Did you ever help them in their business? ( ) No ( ) Yes

13. Did any of your relatives besides your mother or father ever own their own
business?

( ) No

( ✓ ) Yes. Did you ever help them in their business? ( ) No ( ✓ ) Yes

14. Did any of your friends’ fathers or mothers own their own business, or
previously owned?

( ) No ( ✓ ) Yes

15. Cite three friends of yours and their occupations:

a. Name: Erna Ibrahim

Profession: Pelaku Usaha/Pembuat Kue Self-employed? ( ✓ ) Yes ( ) No

b. Name: Wiwin otaya

Profession: Pelaku Usaha/Pembuat Kue Self- employed? ( ✓ ) Yes ( ) No

c. Name: Dewi.mustaga

Profession: Pelaku Usaha/Pembuat Kue Self- employed? ( ✓ ) Yes ( ) No

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16.How many people do you know well personally who runs their own business?
Lebih dari 100 orang __________________________________________

17. In your family, are you....

( ✓ ) the oldest child born ( ) the youngest child born ( ) neither one

18. Have your ever travelled abroad?

( ✓ ) No

( ) Yes Country: _______________________How many times ?

____________

Country: _______________________How many times? ____________

Country: _______________________How many times? ____________

Country: _______________________How many times? ____________

Country: _______________________How many times? ____________

In average, how many times a year do you travel abroad? __________

19. On average, how many times a year do you travel to places in your country
outside of the region where you were born or where you currently live?

6 kali dalam setahun _______________________________________

20. Please list below your past 3 work experiences – stating most recent job first:

Employer Start date End date For how long have

(mm/year) (mm/year) you been in

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 managerial roles?
Perusahan Maret 1991 Desember 1994 3 Tahun 9 Bulan
kecantikan
Apartemen February 1995 September 1995 7 Bulan
Papilon
Supplier February 1998 Maret 1999 1 tahun
PT Nasional Gobel

21. Have you ever tried to start your own business?

( ) No

( ✓ ) Yes. What happened to this business? ( ) It is my current business

( ✓ ) It is still my current
business, but I also have other
businesses running in parallel
(note: please, always refer to
your core business when
describing your entrepreneurial
activities)

( ) No longer exists

( ) Sold to a third party

( ) Sold to the other

shareholders

22. Are you currently self-employed?

( ✓ ) No ( ) Yes

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23. If you run your own business (with or without company ID), please indicate the
the following:

Sector: Kuliner ( ✓ ) Trade ( ) Industry ( ) Services ( ) Agriculture

Years of operations: January 2015

Nº of employees: 3 Nº shareholders: 1

Average monthly revenue (IDR): 60.000.000 (total monthly amount of income

generated by the sale of goods or services )

Average monthly gross profit (IDR): 50.000.000 (revenue minus the cost of
producing the good/services sold)

Is your company a franchise? ( ✓ ) No ( ) Yes. Which one?

_______________

24. If you are you employed, please indicate:

Name of the employer: __________________________________________________

City where you are working: _____________________________________________

Sector: ( ) Trade ( ) Industry ( ) Services ( ) Rural

Is this company a franchise? ( ) No ( ) Yes. Which one?

____

What is your position: _________________________________________________

How long have you been working here? ________________ How many time you
have been promoted? ___________

How many people do you manage?

_________________________________________

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25. At this stage, how do you define your willingness to start your own business,
or to expand your current (if you have one)?

Very weak Weak I can’t assess Strong Very strong

26. At this stage, what are the chances of success/ expansion for your business?

10% 20% 30% 40% 50%

60% 70% 80% 90% 100%

Please explain why : Saya tidak bisa menilai, peluang kesuksesan saya berada di
50%. Alasannya karena dengan keadaan sekarang perekonomian yg tidak bisa
saya prediksi, maka dari itu saya juga tidak bisa memprediksi bisnis saya tetapi
saya punya semangat untuk mengembangan usaha saya.

______________________________________________________________________

27. What is amount you think is necessary for you to start your own business, or
to expand your current one?

IRD 100.000.000 _______

28. From the above mentioned amount, how much do you already have as own
capital?

IRD 70.000.000 ____________

29. Do you meet the necessary requirements to obtain banking credit/finance to

start a business/ or expand your current one?

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( ) No ( ✓ ) Yes. How much? IRD 40.000.000 __________

30. Where do you intend to request funds to initiate a business/expand your

current one?

( ) The sum of my current financial resources are sufficient.

( ) Family/friends.

( ) From new businesses activities

( ✓ ) Other. Which one? Modal Tabungan saya sendiri ____________________

31. What made you start a business...

( ) Lack of available employment and formal income

( ) the best alternative, beyond my current employment and formal income

( ) it complements my current employment and formal income

( ✓ ) I saw a business opportunity

32. Do you own your the home, apartment, land where you are currently living?

( ) No ( ✓ ) Yes

33. In your point of view, what factors mostly contribute to the success of an
entrepreneur? (rate your answer on a scale from 1-8, where 1 is the most
important factor and 8 the least – do not repeat the rating)

( 1 ) Money . To be a successful entrepreneur, one needs capital

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( 3 ) Luck. In the today’s competitive environment, one needs a lot of luck to be a
successful entrepreneur

( 2 ) Technical knowledge. Without a good education background, success is not

achievable

( 1 ) Talent for business. The most successful entrepreneurs have a talent to run
and set up a business

( 3 ) A good team. Without a good team (qualified people), the entrepreneur cannot
succeed

( 2 ) A good business idea. In today’s environment, one needs a different business

idea from what already exists on the market

( 3 ) Motivation. Without motivation and discipline, one cannot succeed.

( 3 ) Friends and strong networking . In today’s environment, an entrepreneur

cannot succeed without valuable contacts

34. In your point of view, what factors mostly hinder the success of entrepreneurs
in your country? (rate your answer on a scale from 1-6, where 1 is the most
important factor and 6 the least – do not repeat the rating)

( 4 ) The government. The bureaucracy makes it more difficult for an entrepreneur

to succeed

( 4 ) The economy. High inflation and unemployment make it more difficult for an
entrepreneur to succeed

( 4 ) Lack of technical preparation. In general, entrepreneurs lack knowledge on

some areas of business operations.

( 4 ) The lack of talent for business. Many people who have no talent for business
yet engage in the business world.

( 4 ) The competition. The market is saturated with companies trying to compete

for customer attention

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( 3 ) The lack of motivation. Many entrepreneurs are not willing to invest 100% of
their efforts on their business

35. Do you agree or disagree with the following statement:

“At work place, the openness to new opportunities is more important than job
security”.

( ✓ ) Entirely agree ( ) Partially agree

( ) Partially disagree ( ) Entirely disagree

36. Do you agree or disagree with the following statement:

“In Indonesia, there are many opportunities for people like me to set up a
business”.

( ) Entirely agree ( ) Partially agree

( ✓ ) Partially disagree ( ) Entirely disagree

37. Use your imagination and try to think of as many uses as possible for sawdust
or products that could be made of sawdust.:

Lemari Serbuk bisa jadi pelet dan bahan kerajinan

38. If today, you would be given the opportunity to have the same role and salary
as your current supervisor – for the next 5 years - would you accept it?

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( ) Yes. Why?
____________________________________

( ✓ )No.

Saya tidak k ingin merasakan kerja di bawah perintah orang lain_______________

39. Imagine that you have been awarded with IRD 450,000 to spend as you wish.
How would you make use of this money?

First use: Beli Stiker

Second use: Plastik

Third use: Segel

40. Please describe your current business or potential idea to set up a business.
Describe in detail the characteristics of the business, the target market, products
or services, how your company stands out from competitors, etc.:

Usaha saya bergerak di bidang kuliner dan saya menjunjung tinggi atas
kelayakan produksi dan menjaga kualitas produk saya.

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___________________________

Signature of the applicant

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