Candidate form Entry criteria 1. You must be currently and have been for at least [3] years the lead/senior executive director of a business (not a subsidiary or division) and therefore, primarily responsible for your business s success. 2. Your business is based or has its chief operations in your country. 3. Your business has been incorporated for at least three years. 4. Your organization must have a minimum of 10 staff members. 5. You must be a significant shareholder in the business 6. You and your company are of good conduct. Personal Name: Company: Job Title: Address: Telephone: Fax: Email: Date of birth: Board Member since: Founder : Yes No Your % ownership of the business now versus previous maximum business ownership [%]
Current involvement in other businesses: Previous involvement in other businesses: Have you entered Entrepreneur Of The Year before? If yes, in what year? Business Business name (as on company accounts): Business address (head office or principal place of business): Website: Telephone: Fax: Company registration number: Company incorporation date: Private business/private business venture backed/market Listed/:
If Private Business what is the ownership structure: If venture backed which PE/VC and what is the ownership structure: If market listed which market (s) and date of listing. Brief description of current business (core product/service and key markets in 50 words max) Number of staff this year/1 yr ago/2 yrs ago/3 yrs ago/4 yrs ago/5 years ago.
Has the business undergone mergers/acquisitions? if so please provide details Year business founded. Year you joined the business. Year you assumed leadership Financial performance 2 years audited financial accounts to be submitted with this form. [If you cannot submit audited accounts please explain why] The below figures are required for: Half year Most recent Second most recent Third most recent management accounts audited year end audited year end audited year end most recent unaudited (audited figures only) (audited figures only) (audited figures only) Financial year end date: Turnover: Geographical split of turnover [% domestic/% European/% ROW] Earnings Before Interest, Tax, Depreciation & Amortization (EBITDA) Profit before tax Net assets
Contact details for CFO, or other, who we may contact regarding questions related to your financial. Contacts Declaration and authority to use References may be sought for finalists. Have you or your business been the subject of an investigation by a government, criminal or regulatory authority in the last 5 years? If yes, please provide brief details. I confirm that, to the best of my knowledge and belief, the provided herein and in the profile and other documents attached is true and complete. I understand that the selection of successful entrants will be within the sole discretion of the panel of judges and Ernst & Young and that such decisions by the judges and/or Ernst & Young are final. I also understand that the judges panel and Ernst & Young reserve the right to deselect an entrant at any stage of the programme. I understand that the I provide relating to this entry form will be used by Ernst & Young, its affiliates, the sponsors, and the independent regional and national judges panels in the selection process for Ernst & Young Entrepreneur Of The Year. I also understand that the may be used for research, educational, media related activity and any other purpose. I agree that Ernst & Young, the sponsors, and their affiliates may also from time to time use the details provided to contact me with details of services, goods or events that may be of interest. I hereby authorise the use and public release, in connection with the Ernst & Young Entrepreneur Of The Year programme and/or Entrepreneur Of The Year Institute and/or eoyclub, of my name, my business s name and logo, entry, photographs, and video recordings of me from whatever source and business logo. I agree that no compensation shall be due to me or my business for such usage. I understand that my nomination cannot be withdrawn once submitted. Entrant s signature... Date... (required for entry to be considered) To enter Complete this form Please return to: Jeddah, KSA.eoy@sa.ey.com Jordan, jordan.eoy@jo.ey.com Attention: EOY 2013 Committee Be sure to include: 2 years audited accounts