1 of 6DESJARDINS AwARDS 2015 • YOUNGENTREPRENEURs

ELIGIBILITY CRITERIA• Companymanagedbyoneormoreyoungentrepreneur(s)

between18and35yearsold.• Companyinoperationforatleast1yearandnomorethan5

years.• CompanyheadquarterslocatedinQuebecorOntario.

JURY AND SELECTION CRITERIAAjurywillbeappointedbyDesjardinstoimpartiallyevaluatecandidatesthrougharigorousandobjectiveprocessbasedonthefollowingselectioncriteria:

• Innovationandoriginality;• Leadershipandvision;• Accomplishmentanddevelopmentpotential;• NumberofjobscreatedinCanada;• Financialstructure;• Socialinvolvementinthecommunity.

YesThecompanyhasbeeninoperationforatleast1year andnomorethan5years(asofOctober15,2015)

Legalstructure ofthecompany

No

INcorporated

Dateofstartofoperations

regIstered cooperatIve other (specIfY)

www.

LegalnameoftheCompany

Nameofthepersonsubmittingtheapplication

Titleofthepersonsubmittingtheapplication

Businesssector

GENERAL INfORmATION

Civicno.

Telephone

Corporatewebsite

City

ADDRESS Of ThE COmpANY (HeadOffice)

Street Suite

PostalCodeProvince

Note :Pleasedonotexceedthespaceprovided.Ifnecessary,youmayattachasingle8.5"x11"sheettocompleteyouranswers.

Mr. Ms.

Phonenumberofthepersonsubmittingtheapplication Emailaddressofthepersonsubmittingtheapplication

NameofthePresident Mr. Ms.

Fax

Email

Yearthecompanywascreated

Nameoftheaccountmanager

Nameofthebusinesscentre,caisseorsubsidiary Transit

CAISSE OR BUSINESS CENTRE INfORmATION (ifthecompanyisaDesjardinsmember)

COmpANY’S mISSION (purpose)

Mr. Ms.

Deadline for applications: March 30, 2015

young entrepreneursaward

Nameofthecompanythepersonsubmittingtheapplicationisworkigfor

2 of 6DESJARDINS AwARDS 2015 • YOUNGENTREPRENEURs

COmpANY pROfILE

Briefly present the company (history, products and/or services, company’s evolution since creation, etc.).Maximum 15 lines or 225 words

1

AChIEVEmENTS

Briefly present the company’s significant accomplishments and major steps taken to date.Maximum 10 lines or 150 words

3

mARKETS

Briefly describe the company’s markets (current and targeted clientele, concurrence, etc.).Maximum 15 lines or 225 words

2

3 of 6DESJARDINS AwARDS 2015 • YOUNGENTREPRENEURs

DEVELOpmENT

What are the company’s development plans for the next three years? (activities, expansion, international com-merce, human ressources, equipment, etc.).Maximum 20 lines or 300 words

4

fINANCING

Briefly describe the company’s financial structure and its sources of financing.Maximum 20 lines or 300 words

5

4 of 6DESJARDINS AwARDS 2015 • YOUNGENTREPRENEURs

Analysis of financial position (for the past three years, if applicable).6

mANAGEmENT TEAm

List all the people on the management team, their title, name and percentage of shares held.7

Name

2)

1)

3)

4)

5)

6)

7)

Title Age% of shares held

2012 2013 2014

a) Sales $ $ $

b) Workingcapitalratio Currentassets

Currentliabilities% % %

c) Currentdebtontotalfinancing % % %

d) Long-termdebtontotalfinancing % % %

e) Totalfinancing $ $ $

f) Grossprofit =Grossmargin Sales

% % %

g) Netincome =Netprofitmargin Sales

% % %

h) Numberofemployees

i) InvestmentinR&D $ $ $

j) Owners’equity $ $ $

5 of 6DESJARDINS AwARDS 2015 • YOUNGENTREPRENEURs

BOARD Of DIRECTORS OR CONSULTING COmmITTEE

If the company has a board of directors or a consulting committee with external people, name them, briefly describe their experience and indicate how often they meets.

8

Name

2)

1)

3)

4)

5)

6)

7)

Title Experience

Frequencyofmeetings:

mENTOR

Please name any mentors who assist the company’s decision-makers and describe their role and the support they provide.Maximum 5 lines or 75 words

9

STRENGThS

Briefly explain the company’s greatest strengths.Maximum 5 lines or 75 words

10

CONTRIBUTION TO ThE COmmUNITY

The company’s social involvement and outreach (regional, provincial, national and international).Maximum 5 lines or 75 words

11

If you had to choose one aspect to represent and promote the company, what would it be?Maximum 5 lines or 75 words

12

6 of 6DESJARDINS AwARDS 2015 • YOUNGENTREPRENEURs

Inpartnershipwith

NameofcompanyPresidentorRespondent

AuTHORIzATIONOFPRESIDENTORRESPONDENT

Check here

Iattestthattheinformationprovidedaboveistrueandaccurate,bothpersonallyandonbehalfoftheCompany.

Authorizedat ,this th dayof 2015 city day month

Pleasestateyourpositionatthecompany

CONfIDENTIALITY

Theinformationprovidedinthisdocumentwillbeusedsolelyforevaluationpurposesandwillnot,underanycircumstances,bedisclosedwithoutpriorconsentfromthecompany.

DECLARATION Of ACCURACY Of INfORmATION

Iherebycertifythatthecompany’soperationsareinfullcompliancewithcurrentprovincialandCanadianlawsandstandards,andthattheinformationinthisdocumentisaccurateandcomplete.Icertifythatnoneofthecompany’sdecision-makingpositionsareheldbyDesjardinsemployeesormembersofanyDesjardinsboardofdirectors.Desjardinsandthejurymayrequirewinningcompaniestoprovideproofoftheaccuracyoftheinformationprovidedintheirapplication.

CONSENT

unlessthisdocumenthasbeencompletedbysomeoneexternaltothecompany,thecompanyconsentstotheinformationhereinbeing disclosed to the members of the jury and other parties involved in this award. If a person external to the company hascompletedthisdocument,heorshemustobtainconsentfromanauthorizedpersonatthecompanytodisclosetheinformationprovidedhereinbeforesubmittingittothejury.

Forquestionsortosubmittheform(byMarch30,2015,atthelatest):Karen Lafleur, Marketing Division 514 281-7000 or 1 866 866-7000, ext. 5551820 prixdesjardinsentrepreneurs@desjardins.com

Mr. Ms.