#1GOPC Form GIPC/R1 GHANA INVESTMENT PROMOTION CENTRE INVESTOR REGISTRATION FORM Under the Ghana Investment Promotion Centre Act 2013 (Act 865) Information Supplied will be treated as CONFIDENTIAL To be completed and emailed to:- The Chief Executive Officer Ghana Investment Promotion Centre P. O. Box M193 Ministries Accra - Email: [email protected] FOR GIPC OFFICE USE ONLY (i) Date Received at GIPC: (ii) Minimum Foreign Equity Capital requirement satisfied ( ) (iii) Application received in good order ( ) (iv) Name of Registration Officer: (v) Signature: (vi) Date Certificate Issued: (vii) Certificate Number:#2PART 1: ENTERPRISE DATA 1. General: (a) Name of Enterprise:.. (b) Address of Enterprise:........ (i) in Ghana Tel: Fax:.............. Email:. (ii) outside Ghana Tel:................... Fax:................... Email:......... (c) Head or Registered Office: Street/Plot /HNo: District: Telephone: (d) Contact Person: (e) Registrar General's Particulars: Town: Region: Email: (i) Certificate of Incorporation No:.. (ii) Type of enterprise (please tick): [ ] Sole Proprietorship [ ] Partnership ( ) Private Limited Liability [ ] Public Limited Liability ( ) Co-operative Society ( ) External Company (Liaison Office) ( ) Statutory Board/Gov't & Quasi-Gov't Institution 2. Equity Structure: Name of Company (a) (b) Or Individual (c) (d) (e) * Nationality Shareholding (%) Paid-up Equity .. US$........... .US$... .US$... .. US$ .US$. In the case of Non-Ghanaian shareholder(s) please attach as evidence Bank transfer receipts and/or Customs Bill of Entries as appropriate and Import Declaration Form (IDF). * In the case of a Joint Venture with a Ghanaian, the Ghanaian must have a minimum of 10% shares in the enterprise#3PART 2: PROJECT DATA 1. Project Definition/Concept: Give a brief description of the project: 2. Location of Project (if different from Head Office): (a) (b) Street/Plot /HNo: District: --------- Town: Region: ▪▪▪▪▪▪▪--------- 3. Major Produce/Product(s)/Service and Output level per annum: (also indicate percentage for export) (a). (b) (c) (d) (e) . 4. Major Raw materials: (a) (b). (c) (d) Item(s) (e) Local Source of Supply Foreign 5. Do you intend to enter into any Technology Transfer Agreement? Yes [ ] No [ ] if yes complete form GIPC/T1 in accordance with section 37 of Investment Act 6. Describe effluence and other pollutants resulting from your enterprise, and measures to control same. (Note: Environmental Protection Agency (EPA) may require you to submit your project for Environmental Impact Assessment) 3#47. Project Implementation: Implementation Stages (a) Land or Site acquired (b) Land/Site Preparation completed (c) Recruitmentof Manpower initiated (d) Building Construction started (e) Building Construction completed (f) Machinery Installation started (g) Machinery Installation completed (h) Trial Production started (not applicable to services) (i) Commercial Production/Operations started or service commenced 8. Project Cost and Financing: (A) Sources of Funds: * (i) Local Equity US$ (ii) Foreign Equity US$ * (iii) Local Loan US$ (iv) Foreign Loan US$ (v) Suppliers Credit US$ (vi) Others (Specify) US$ (vii) TOTAL US$ * Exchange Rate used: US$1.00 = GH¢.….……......... (B) Application of Funds: i. Land & Development ii. Building & Structures iii. Machinery & Equipment iv. Motor Vehicles v. Furniture & Office Equipment vi. Working Capital vii. Others (Specify) viii. Total (i - vii) Estimated Date 20....... (US$) 20....... 20....... (US$) (US$) 4#59. Employment: Managerial-Ghanaian Managerial-Non-Ghanaian Skilled-Ghanaian Skilled-Non-Ghanaian Give the number of employees involved Existing Project New Project Present Capacity At Full Capacity Initial At Full Capacity Capacity Unskilled-Ghanaian TOTAL 10. Have you entered into any Agreement with the Centre under previous Investment Laws? Yes [ ] No [ ] 11. Indicate whether you need any assistance from the Centre in the following areas: Land Acquisition Electricity Supply Water Supply Telephone Connection Authorization and Permits [ ] [ ] [ ] [ ] [ ] Specify (a) (b) (c) (d) (e) Any other Assistance [ ] Specify --------------- ▪▪▪▪▪▪▪▪▪-----------------------------▪▪▪ 10#612. Declaration: I/We hereby confirm that the answers given on this Registration Form are true and correct to the best of my/our knowledge. I/We would be pleased to provide you with any further information you may require. ▪▪▪▪▪▪▪--------------- SIGNATURE ▪▪▪▪▪▪▪▪----------------------- DATE 13. Attachments: ----------------------▪▪▪ FULL NAME (IN BLOCK LETTERS) PLACE --------------- OFFICIAL USE Please submit the following documents together with this form:- (a) Photostat copy of Registrar General's Certificate of Registration (b) Certified true copy of Company's Regulation [ ] [ ] (c) Proof of Marriage & residence, in the case of Section 28(5) of GIPC Act 865 [ ] (d) Any other requirement as may be applicable [ ] Notes: 1. If there should be changes in respect of the following:- Enterprise name/status (a) (b) (c) (d) Location Ownership Structure; and Project Concept After this registration, please notify the Centre accordingly. 2. Any subsequent changes in ownership structure shall have due regard to the minimum foreign equity requirement. 16