BUSINESS INFORMATION

LEGAL COMPANY NAME: / BUSINESS ID NUMBER:
TRADE NAMES / DBAs: / INCORPORATION DATE:
NATURE OF BUSINESS: / NUMBER OF EMPLOYEES:
BUSINESS ADDRESS: / PHONE #: ( ) -
CITY: / PROVINCE: / POSTAL CODE: / WEBSITE:
ENTITY TYPE: CORPORATION LLC SOLE PROPRIETORSHIP PARTNERSHIP
TYPE OF FINANCING REQUESTED:
FACILITY AMOUNT REQUESTED: $
INTENDED USE OF FUNDS:
PREVIOUS ANNUAL SALES: $ / PROJECTED ANNUAL SALES: $
PREVIOUS NET INCOME: $ / PROJECTED NET INCOME: $

OWNER INFORMATION

OWNER / MANAGEMENT / SHAREHOLDER CONTACT(S) FULL LEGAL NAME / TITLE / % SHARES HELD / SIGNING AUTHORITY
YES NO
YES NO
YES NO
YES NO
PLEASE PROVIDE A CORPORATE ORGANIZATION CHART IF APPLICABLE

ACCOUNTS RECEIVABLE INFORMATION (IF FACTORING)

RECEIVABLES BALANCE:
CURRENT:
$ / 1-30 DAYS:
$ / 31-60 DAYS:
$ / 61-90 DAYS:
$ / 90+ DAYS:
$ / TOTAL:
$
AVERAGE INVOICE AMOUNT: $ / AMOUNT TO FACTOR MONTHLY: $
HAVE YOU EVER FACTORED OR BORROWED AGAINST YOUR RECEIVABLES? NO YES WITH WHOM?
ANY CURRENT LIENS ON YOUR ACCOUNT RECEIVABLES? NO YES BY WHOM?
ARE THERE ANY HOLDABACKS? NO YES / PROGRESS BILLING OR MILESTONE PAYMENTS? NO YES

CUSTOMER INFORMATION

TOP 5 CUSTOMERS / FULL ADDRESS / ESTIMATED ANNUAL SALES
/ $
/ $
/ $
/ $
/ $

BANKING INFORMATION

BANK NAME: / BRANCH LOCATION: / CONTACT NAME:
TELEPHONE #: ( ) - / HOW LONG HAVE YOU BEEN AT THIS BANK: YEAR(S) / ACCOUNT #:
OPERATING LINE AMOUNT AUTHORIZED: $ / AVERAGE AMOUNT OWING: $
BANK SECURITY / COLLATERAL PLEDGED: ACCOUNTS RECEIVABLE INVENTORY EQUIPMENT REAL ESTATE OTHER:
DO YOU HAVE ANY FINANCING FACILITIES WITH OTHER BANKS? NO YES IF YES, PLEASE PROVIDE THE INFORMATION REQUESTED ABOVE.

ADDITIONAL INFORMATION

PAYROLL SERVICE USED: NO YES IF YES, PLEASE SPECIFY
DOES COMPANY HAVE ANY TAXES PAST DUE? NO YES IF YES, PLEASE SPECIFY
IF “YES”, HAVE ARRANGEMENT TO REPAY BEEN AGREED UPON? NO YES IF YES, ATTACH DETAILS.
HAS THE COMPANY BEEN INVOLVED IN ANY LITIGATION, EITHER CURRENTLY OR HISTORICALLY? NO YES
IF “YES”, PLEASE SPECIFIY:
HAVE THE OWNERS, OFFICERS OR KEY MANAGERS OF THE COMPANY EVER BEEN CONVICTED OF A CRIMINAL OFFENCE? NO YES
IF “YES”, PLEASE SPECIFY:
HAS THE COMPAY EVER FILED FOR BANKRUPTCY? NO YES
IF “YES”, PLEASE SPECIFY:
HAS THE COMPANY MOVED LOCATIONS IN THE PAST 5 YEARS? NO YES
IF “YES”, PLEASE SPECIFY:
NAME OF CORPORATE LAWYER: / PHONE #: ( ) -
NAME OF EXTERNAL ACCOUNTANT: / PHONE #: ( ) -

CERTIFICATION

I hereby certify on behalf of Applicant that the information provided in this Application is true, accurate and complete. Permission is hereby granted for a confidential credit investigation. A copy of this form shall be good and sufficient authority for anyone having confidential or other information about the financial position of Applicant to disclose such information to Navroze Capital and its Associates upon request.

If representations are subsequently found to be incorrect or incomplete, Navroze Capital and its Associates reserves the right to reject this application and cancel any contract that may be negotiated and shall not be obliged to fulfil any agreement with Applicant, verbal or written. Applicant agrees that any expenses incurred by Navroze Capital and its Associates, because of reliance by it upon incomplete or incorrect statements made by Applicant herein are chargeable to Applicant.

I consent to Navroze Capital and its Associates sending me electronic messages with respect to the services provided by them. I understand that I may withdraw my consent at any time.

ALL OWNERS / SHAREHOLDERS MUST SIGN

PRINT NAME AND TITLE OF SIGNING OFFICER / SIGNATURE OF AUTHORIZED SIGNING OFFICER / DATE
PRINT NAME AND TITLE OF SIGNING OFFICER / SIGNATURE OF AUTHORIZED SIGNING OFFICER / DATE
PRINT NAME AND TITLE OF SIGNING OFFICER / SIGNATURE OF AUTHORIZED SIGNING OFFICER / DATE

TO EXPEDITE PROCESSING, DOCUMENTS MOST COMMONLY REQUIRED INCLUDE:

APPLICATION, PERSONAL FINANCIAL STATEMENT, LAST 2 YEARS FINANCIAL STATEMENTS, LATEST INTERIM FINANCIAL STATEMENTS, DRIVER’S LICENCE FOR ID,
ARTICLES OF INCORPORATION, LAST 6 MONTHS OF BANK STATEMENTS, BUSINESS PLAN, APPRAISALS (IF APPLICABLE), AR AND AP AGING REPORT (FOR FACTORING).

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NCC2018