Project Finance Application Form Intro Short

Business / Project Finance Application Form This Section is for Official Use Primary Officer: Prepared By: Date Prepared: Country: Client contact person: Telephone: Company: Fax: Email: Contract Signed: Yes / No ________New Relationship New Business: Yes / No ________Existing Relationship Officer Sign: _________________ Notes / Remarks: BUSINESS INFORMATION - The Company Business Name: Address: Telephone ( ) Company Registration #: Affiliated Companies Name(s) Address Telephone ( ) Fax Number ( ) Email: Legal Structure: Proprietorship __________Partnership __________ Sub-Chapter S_______ Corporation ________ Non-Profit _________ Individual __________ LLC ________ Nature of Business Year Established Number of Employees Years at Present Location [ ] Own [ ] Lease Accountant Telephone ( ) Insurance Agent Telephone ( ) Attorney Telephone ( ) Brief Project Description : Knowledge Transfer & Economic Growth Development Consultants www.convergenceconsulting.org

Ownership Distribution: (List stockholders, partners, owner Note: Attach separate sheet if additional space names) needed. Name Title # of Years % $ Name Title # of Years % $ Name Title # of Years % $ Product / Service Description: Market Position (description of demand and supply, competitive position, future orientation etc)1 Client Profile (Breakdown in terms of sector, total assets, turnover, # of employees etc) 1 Summary of audited financial statements over the past 3 years1 Business Plan / Project Projections for the next 5 years1 Critical Success Factors1 Risk Analysis & Mitigation 1 FINANCIAL INFORMATION Bankers (Name of Institution) Contact Person / Position 1 If a comprehensive feasibility study or business plan is available then a summary of these points will be sufficient here. Knowledge Transfer & Economic Growth Development Consultants www.convergenceconsulting.org

Credit Relationships: Please provide details of your business credit relationships below: Original Loan Amount Maturity Name of Purpose of Loan Amount Presently Owing Repayment Date Creditor Terms $ $ $ $ $ $ $ $ FINANCE REQUESTED Amount of Finance Requested Type of Finance $ [ ] Loans [ ] Guarantees Requested Term of Finance ___________________ [ ] Syndicated Loans [ ] Equity & Quasi-Equity [ ] Other Specific Finance Purpose (Check all that apply) [ ] Working Capital [ ] Other (State type of loan required and loan [ ] Finance Purchase of Inventory purpose) [ ] Finance Purchase of Equipment ____________________________________ [ ] Finance Purchase of Business ____________________________________ [ ] Refinance Existing Loan or Debts ____________________________________ Collateral Available* (Check all that apply) [ ] All Assets (accounts receivable, inventory, machinery and equipment) [ ] Specific Equipment (Please attach equipment list, including serial numbers or description of equipment, and invoices for new equipment.) [ ] Real Estate Value in $: ________________________ Meters 2 ________________ Acres __________ [ ] Cash on Deposit at (Name of bank & Current Branch __________________ Account # _____________ Balance) [ ] Personal Assets [ ] Local Bank Guarantee. Name of Bank: ____________________________________________________ Knowledge Transfer & Economic Growth Development Consultants www.convergenceconsulting.org

Project Finance Application Form Intro Short

by Convergence Consulting on Dec 11, 2009

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Project Finance Application Form Intro Short — Document Transcript