Convergence Consulting is a recognized Emerging Market Finance Broker, specializing in customized financial solutions for emerging markets throughout the world. • International Project Finance • • Project / Equity Capital • • Export Credit Agency Programs • • Risk Mitigation Insurance •

1. 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

2. 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

3. 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