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Impact Enterprise Registration Form
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Basic Profile
*Organization Name
*First Name
*Last Name
*Job Title
*Email Address
Website
*Country of Operation
Bangladesh
Cambodia
India
Indonesia
Myanmar
Nepal
Philippines
Sri Lanka
Thailand
Vietnam
Other
Please Specify
*Country of Headquarters
Same as operations
Different from operations (Please specify)
Please Specify
Financial Profile
*What legal entity is the company registered as?
For Profit
NGO
Not-for-profit
Cooperative
Hybrid (Not-for-profit with for-profit)
Not yet registered
*Do you have revenue generating operations? (not including grants)
Yes
No
*What is your total revenue in USD (last twelve months)? (not including grants)
< 100,000
100,000-500,000
500,000-1 million
1-5million
>5million
*What type of financing are you looking for?
Grant
Debt
*What is your total revenue in USD (last twelve months)?
< 100,000
100,000-500,000
500,000-1million
1-5million
>5million
*Have you previously raised equity (or quasi-equity funding) from outside investor(s) (e.g. reputable angels, institutional, VC)? (Not including founders, friends, and family)
Yes
No
*Is your company net profit positive? (last 12 months)
Not profitable
Break-even
Profitable
*What type of financing are you looking for?
Equity
Quasi-equity (e.g. Convertible note, Revenue-linked debt)
Debt
Grant
No preference
*What is the purpose of the loan? (Select all that apply)
Improve short-term liquidity (Working Capital Loan)
Invest in new assets to increase profitability, market share or net cash flow (Investment Loan)
Others (Please specify)
Please Specify
*What is your debt raise amount in USD (current round)?
< $100,000
> $100,000
*Have you previously raised debt from private individuals that are not shareholders or in any other way affiliated to your company (e.g. suppliers, buyers, etc.)?
Yes
No
*Have you previously raised debt from informal or formal lending institutions (e.g. MFIs, NGOs, cooperatives or banks?
Yes
No
*Have you ever defaulted on a personal or a business loan?
Yes
No
*Is your Working Capital (Current Assets - Current Liabilities) positive (most recent period)?
Yes
No
*What type of collateral could you provide for this debt raise?
Personal guarantee
Asset-based collateral (including e.g. accounts receivables, inventory, machinery, equipment or real estate)
Others (Please specify)
No collateral
Please Specify
*What is your capital raise amount in USD (current round)?
*How would you categorize your current funding round?
Pilot
Seed funding with pilot
Bridge to Series A
Series A
Bridge to Series B
Series B & beyond
Impact Profile
*What sector(s) does your company operate in? (Select all that apply)
Agriculture
Education
Energy
Environment
Inclusive Finance
Health
Housing/Community Facilities
Water
Media
Fair Trade
Livelihood
Technology
To be determined
Others (Please Specify)
Please Specify
*Which part of the value chain is your company active in? (Select all that apply)
Pre-production/ sourcing raw materials
Production
Processing
Distribution
Retail
Service
Platform / Market
To be determined
Others (Please specify)
Please Specify
*Number of Employees (Full Time Equivalent)
< 5
5-10
10-20
20-30
> 30
*Does your company create positive social impact?
Yes
No
*If no, does your company plan to create positive social impact in the future?
Yes
No
*How does/will your company create positive social impact? (Select all that apply)
Creating or improving livelihoods
Increasing skills and knowledge (e.g. financial literacy training, training in organic farming, etc.)
Access to essential goods and services (e.g. education, financial services, healthcare services, water and sanitation, energy supplies, markets)
Others (Please specify)
Please Specify
*Who are your key beneficiaries?
Suppliers
Employees
Customers
Local Community
Others (Please specify)
Please Specify
*Which under-served group does your key beneficiaries fall under? (Select all that apply)
Rural poor
Urban poor
Marginalized women
Children
Elderly
People with disabilities
Ethnic minorities
Others (Please specify)
None
Please Specify
*Does your company create positive environmental impact?
Yes
No
*If no, does your company plan to create positive environmental impact in the future?
Yes
No
*What is the main positive environmental impact your company is creating/will create? (Select all that apply)
Air pollution management (E.g. sulfur dioxide, oxides of nitrogen, Particulate Matter, Volatile Organic Compounds)
Climate change mitigation (E.g. carbon dioxide, methane, nitrous oxide)
Land rehabilitation (E.g. reforestation, increased soil fertility, remediation and clean-up)
Natural resource conservation (E.g. Waste minimization, materials reuse, recycling)
Agricultural/ livestock productivity
Biodiversity conservation (E.g. endangered animals, native species)
Water conservation
Other (Please specify)
Please Specify
Legal Notice
Impact Enterprises that join Impact Partners acknowledge that although membership on the platform will enhance their visibility to Impact Investors, it is by no means a guarantee that they will be able to successfully raise capital. By submitting this form and registering on Impact Partners, the Impact Enterprise therefore agrees to hold Impact Investment Exchange (Asia) Pte. Ltd. harmless for any alleged damages from any inability to raise investment capital.
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