Apply Now : ClearStar Business Lending Inc.

AGENCY INFORMATION PROFILE

All information provided within this AIP form is confidential. This information is requested by ClearStar Business Lending, Inc. and in compliance with ClearStar policy. Any information that you volunteer in this form will be held in the strictest confidence and will not be disclosed to any third party outside of our identity verification processes and Agency registration processing department. Failure to provide full. Correct and true information may lead to refusal of your application.

This information will remain confidential at all times

SECTION 1 : ABOUT THE PROJECT OR SPECIAL COMPANY

Name of the project

Name of Applicant or Company

Was your company created specially for the project (Special Purpose Vehicle)
YesNo

Industry Sector

Holding Company (if applicable)

Contact Person for Project

Please provide a description of the project (5 to 6 sentences)

Investment Required (in USD)

Amount of Equity Available and Contributed including land

Guarantee offered

Estimated Amount of Applicant’s Free Cash available

Estimated Market Value of Applicant’s Free Current Assets

Project Execution / Construction Period

List of Permits, Licenses and Government approval obtained

Any Off-Take Agreements

Existing Debt on Project
YesNo

If Yes, please explain

Total Project Cost

Type of Finance Sought

Loan to Value Ratio

Loan to Cost Ratio

Investor’s Length of Investment

Financial Companies Contacted for Funding

Obstacles encountered that have prevented project for being funded

What best describes your current business stage?
Has never conducted operationsIs in the development stageis currently conducting operationsHas shown a profit in the last fiscal year

What company, if any, is active in doing the accounting for your company / project?

Have you obtained any agreements with suppliers and/or contractors in order to guarantee the development process of the project?
YesNo

Explain your answer

SECTION 2: ABOUT YOU

Family name

Forename(s)

Date of birth

Nationality

Passport expiration date

Place of passport issue

Occupation or profession

Number of dependents

Professional Qualifications

State of health
GoodFairPoor

PERSONAL CONTACT INFORMATION

Your residential address

Town

Postal/zip code

Country

Mobile number (Please include international codes)

Home telephone (Please include international codes)

Office telephone (Please include international codes)

Fax (Please include international codes)

Prefer telephone number (Please include international codes)

Have you ever been a resident of another country in the past ten years
YesNo

If yes, please state previous country of residence

Email address (please provide a confidential email address)

Please provide the below information on your main principal company. This means that if your company is a group of companies, please provide information on the main trading parent of group company. If your company is a Special Purpose Vehicle or Private Subsidiary of a public company, please provide full details on the intended trading company that will be applying for the facilities.

SECTION 3: ABOUT YOUR PRINCIPAL COMPANY

Name of corporation

Company registered number

Registered office of corporation(Please provide full postal address of Registered Office)

Date of incorporation

Jurisdiction of incorporation

Type of corporation
Limited CompanyLimited Liability CompanyPartnershipPublic / Listed Company

Check this box if Special Purpose Vehicle
Special Purpose Vehicle

Number of employees

Turnover of the company
This year

Last year

Netprofit of the company
This year

Last year

What is the main business or purpose of the company?

Date trading started or planes to start

Share capital
Authorized capital:

Fully paid capital:

Trading address
(Please provide a full correspondence address for receiving confidential documents This address does not need to be the Registered Office of the company but Must be an authorized address of the Company or its trading premises/office)
Address for all correspondence

Town

Postal code

Country

Please provide information about the Directors/Officers and Shareholders of your principal company

List of directors

Full name

Date of Birth

Shareholder %

List of shareholders

Full name

Date of Birth

Shareholder %

Have any of the above stated directors:

Ever been made subject to bankruptcy or insolvency order or have been made bankrupt
YesNo

Ever entered into an individual voluntary arrangement (IVA) or company voluntary arrangement (CVA)
YesNo

Ever been banned from acting as a company director
YesNo

Been convicted of a criminal offence for anything other than motoring offenses?
YesNo

If “yes” to any of the above, please provide details

Please complete this page with the Mostdetails possible. Failure to complete this page may delay your application

SECTION 4: ASSET & LIABILITY STATEMENT

PERSONAL (FIRST DIRECTOR OR BENEFICIAL OWNER)

Value of Private Primary Residence

Real Estate Property

Liquid or Cash Accounts

Investments Quoted:(Stocks & Bonds)

Other (please state)

Value of Company Shareholding

Cars /Boats /Aircraft

TOTAL PERSONAL ASSETS

Residential Loans and Mortgages

Commercial Loans and Mortgages

Bank Loans/Overdrafts

Other Credit or Loans:

Other (please state)

Hire Purchase of Lease Contracts

TOTAL PERSONAL LIABILITIES:

CORPORATE / COMPANY ASSETS AND LIABILITIES

Real Estate Property

Liquid or Cash Accounts

Investments

Cars / Boats / Aircrafts

Debtors

TOTAL CORPORATE ASSETS

Secured Loans and Mortgages

Loans or Overdrafts:

Other Liabilities

Hire Purchase & Lease Contracts

Creditors

TOTAL CORPORATE LIABILITIES

Please provide us with details of your Bankers and Legal representative who will be conveying the intended transaction

SECTION 5: ABOUT YOUR COMPANY BANKER (S)

Name of bank(Please provide full details of your company bankers)

Address of your bank/branch

Town

Postal code

Country

Principal account name

Account number

BIC or SWIFT code

Name of account manager

How long has company used this bank?

SECTION 6: ABOUT YOUR SOLICITOR / ATTORNEY OR LEGAL REPRESENTATION

Name of law firm

Name of attorney or solicitor

Address

Town

Postal code

Country

Telephone

Fax

Email address

SECTION 7: ABOUT YOUR REQUIREMENT

Corporate loan (Secured)

Merger and Acquisition

Project finance

Bank guarantee

Standby letter of credit

Credit line against bank instrument or bond

Private equity or stakeholder investment

Other (Please specify)

SECTION 8: PROJECT SCHEDULE

Anticipated project start date

Anticipated completion date

Required Funding Schedule (Amount required each year)

Start

Year 1

Year 2

Year 3

Year 4

Year 5

Project returns

Start EBITDA(percentage)

Year 1

Year 2

Year 3

Year 4

Year 5

Profit / Loss Forecast from Start Date

Start Net Profit/Loss

Year 1

Year 2

Year 3

Year 4

Year 5

SECTION 9: DECLARACION

I understand that the information provided herein and other information that may be attached to this document will be examined in accordance with the due diligence procedures defined under the Laws of Florida, USA, and the invertors’ country. Please accept this form and any other attachments as authorization for ClearStar Business Lending, Inc. and its lenders/investors/co-brokers to undertake any necessary due diligence investigations, including the search of financial, credit history or criminal database in respect of myself, my company, and any other associated parties.

Name

I hereby swear or affirm under penalty of perjury that the information provided herein an in any other attached document is both true and in accurate and I further confirm that any funds to be engaged in this transaction contemplated are derived from non-criminal origin and are good, clean and clear. The origin of all funds is in compliance with Anti-Money Laundering Policies set forth by The Financial Action Task Force (FATC).

Name

Date