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Client Intake Form

Applicants must complete ALL sections of the form in order for the application to be processed. This Intake Form will become part of your contract. Our time is as valuable as yours, so please, only serious applications from individuals who know what they need and have the funds to pay for the requested service. Email to r fax to 832-201-8437 Attn: Proof of Funds Dept.

CLIENT INFORMATION

Principal Name
Nationality
Drivers' License or Passport #
Expiration Date
Date Of Birth
Permanent Address
Primary Phone Number
Secondary Phone Number
Fax Number
E-mail Address

CLIENT BANK INFORMATION

Name of Bank
Branch
Bank Address
Telephone & Fax
Account Number
S.W.I.F.T. Code
Bank Officer #1
Bank Officer #2
Account Name
Account Signatory
Funds Set Aside To Pay Fee’s
Are Funds Liquid, Free & Clear? / YES NO

CLIENT COMPANY INFORMATION

Name of Company
Type of Business Conducted
Business Address
Registered Office
Telephone & Fax Number
Do You Have Any Outstanding Judgments, Law Suits or Tax Liens?
Place of Incorporation
Date of Incorporation
Corporation Registration Number
Legal Advisor & Company Name
Employer Tax ID Number - EIN
Principal Structure of Business / Corporation Partnership Individual LLC

SERVICE REQUESTED

What Kind of Service Do You Need? / POF Blocked Account Bank Instrument
Sizeof Instruments Needed
Do You Have 2.50% of This Amount?
If “NO” Then How Much Do You Have?
Type of Instrument [If Applicable] / BG CD xSBLC/BG
Desired Leasing Term
Desired Closing Date
Do You Require Monetization / Yes No
Recourse or Non-recourse loan
Desired Bank / USA Top A1/P1 Rated
Type of Account Confirmation Required / By Phone Statement MT799 MT760

REFERRING BROKER [IF APPLICABLE]

The following persons are recognized as our Referring Agent(s):

Referring Broker Name
Referring Broker Email & Phone #
Referring Broker Name
Referring Agent Email & Phone #

USE OF ACCOUNT

Provide a detailed description of how you will be using the account/instrument – be as detailed as possible. Applications will be turned down if the description is only 1 -2 sentences. Provide ALL necessary information including required ‘text’, payment and delivery methods:

US PATRIOT ACT CERTIFICATION

All information requested is in accordance with International Money Laundering Regulations and the US Patriot Act

In compliance with the Uniting and strengthening America by Providing Appropriate Tools Required to Intercept and Obstruct Terrorism (US Patriot Actof 2001) and other counter-terrorism laws. Client hereby certifies under penalty of perjury the following:

  1. That all monies tendered or to be deposited in escrow by or on behalf of Client are from a source that is in compliance with all applicable United States of America anti-terrorist financing and asset control laws, statutes and executive orders, and
  2. That all monies received by or on behalf of Client will be used by Client strictly in compliance with all applicable United States of America anti-terrorist and asset control laws, statutes and executive orders.

ACCURACY OF INFORMATION

I personally represent and warrant, under penalty of perjury, that the information provided is accurate and complete. Further, I warrant that I have the legal authority to sign on behalf of my self and/or my company. I agree to notify the leasing provider if the information which has been supplied changes in any manner.

______

Signature

Name of Authorized Signatory
Title
Date

ADDITIONAL DOCUMENTATION REQUIRED

Please attach the following documents when submitting your application:

•Companies: Corporate applicants must provide a Certificate of Incorporation and Corporate Resolution, along with proper identification documents.

•Individuals: Individual applicants must supply two documents which show identification (Color Copy of Passport, State ID, Utility Bill, Etc.)

•Authorized Persons: Associated or authorized applicants must provide two forms of identification to prove their residence and identity.

•Proof Of Funds: all applications must provide a statement showing the funds available for payment of bank fees. All broker fees are paid following the successful deliver of the instrument or monetization if the Monetizer is referred by our group. .

•Executive Summary of Business Plan

•History of Management Group

•Private Placement Non-Solicitation Statement

•Payment of Service Fees:Applications must be submitted with a bank statement showing the ability to pay the amount equal to the leasing fee unless payment will be by ICPO or MT700 following delivery. If payment will be by ICPO. 24 hoursfollowing delivery of the instrument, applicant must verify how many days bank needs to pay the service fee upon delivery. (normal is 1-7) No proof is required when requesting monetization services.

•Verbiage:Applicants must clearly define the verbiage needed for their transaction if there are special conditions. Please provide receiving bank’s requested MT760 verbiage if delivery is to your bank.

•Delivery of SBLC/BG to unknown Monetizer. Applicant must provide the delivery and fee payment procedures of the Monetizer if not utilizing a Monetizer referred by our group.

BANK COORDINATES FOR DELIVERY OF INSTRUMENT ( If Applicable):

BENEFICIARY NAME:
PASSPORT #:
TELEPHONE + FAX#:
EMAIL:
BANK NAME:
BANK ADDRESS:
ACCOUNT NAME:
ACCOUNT NUMBER:
SWIFT CODE:
ABA - ROUTING #:
BANK OFFICER:
BANK OFFICER PHONE / FAX #:

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All information submitted will be handled with strict confidentiality