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µøÈ ¦¯¯ 쾸
À²ˆº¢ðº½÷¨¾©©¿-Àó-¡¾§º¡£í, ¦¿Í¸© Áì½ ¦É¾¤®ö©
¸ò²¾¡À¦©«½¡ò©ŒÀªñ¡ò¡¡È¼¸¡ñ®Á»È...... µøÈÀ¢©®É¾...... -À´õº¤...... -Á¢¸¤......
-Investment Application Form
For Mining Sector
In Lao PDR
To carry out the Prospecting and Exploration and
Technical feasibility Study on the…………….mineralin……….....Village,…………………District, Province……………………………………...
£¿-Á½-¿
(Instruction for filling out Investment Application Form)
¡½-ì÷-¾-¯½-¡º®--£¿-»Éº¤¢ðìö¤êôùÉ-£ö®-«É¸ Áì½ «õ¡-ªÉº¤:
(Please read every question carefully and answer correctly, to the best of your knowledge and legibly (Print or block letters)
- òªò®÷¡£öÀꉾ˜ ¥‡¤¦¾´¾©¨ˆ£¿»Éº¤¦½®ñ®š (Only individual entity can submit this Application Form)
- «É¾-¹¾¡-§Èº¤-¹¸È¾¤-®Èº-¯½-¡º®-£¿-»Éº¤-®Ò-²ð ùÉ-À»ñ©-Àº-¡½-¦¾-§Éº-êɾ¨-£ñ©-ªò©-´¾²Éº´ (If the space provided for your answer is not sufficient, please use separate sheets and attach)
- ì½-®÷-À¯ñ¦½-¡÷-À¤ò¡ó®Ã-¡¾-¢¼-£¿-»Éº¤, áðì½ó ì½®÷À¯ñ¦½¡÷ À¤ò©-ì¾-¦½-¹½-ìñ© ùɺó¤Ã¦Èºñ©ª¾Á졯ȼÃÀ¸ì¾˜.
(Please use Lao kip as a reference in the form. Incase useUS dollarsas a referenceshall be based on current exchange rate at that time)
- «É¾-´ó-Àº¡½¦¾-ºˆÅ-À²†´-Àªó´ ¡½ì÷¾-Á¯-À¯ñ-²¾¦¾-쾸-- Íõ ²¾¦¾-ºñ¤¡ò©--. (Please attach any relevant document(s) in Lao or English language).
- ¦º®-«¾´-¢Ó-´ø- ¡½-ì÷-¾-ªò©-ªÒ (For more information please contact us):
Âê (Tel): (856-- 21) 217012, 223002 Áì½ Í-õ (or)
Á³ñ¡ (Fax): (856 21) 215491,
E- mail:
- ªÉº¤-¨ˆ£¿»Éº¤-ùÉ-£ö® ¥¿-¸ 6 §÷© ªÒ-¡ö´¦‰¤À¦ó´¡¾-ìö¤-êô.
(Please submit 6 copies of your application form)
- °øÉ-ìö¤êô-ªÉº¤À¡ñ®-¦¿-Àö¾-£¿-»Éº¤-¢ð-ìö¤-êô 1 ¦½-®ñ® ĸÉ-À¯ñ-Íñ¡-«¾.
(An extra copy of your application form should be kept for your reference)
쾨¡¾Àº¡½¦¾ê†¨ˆ´ó:
- £¿»Éº¤¢ðìö¤êô ª¾´Á®®²ò´ (Completed Investment Application Form)
- ®ö©-¦½-ÀÎó-¹¨Ó-¡È¼¸-¡ñ®-¡¾--²ñ©ê½¾-£¤¡¾ µ˜¤µõ©¨¯½ê¾ Íõ º¿¸¨-¡¾-ù¨È
¢º¤-®ðìò¦ñ© (Íõ- °øÉ-«õ¡-´º®-¦ò©) (Summary proposal about the development of
the proposedproject certified by President or Managing Director)
- ¯½¹¸ñ© -Áì½ ¯½¦ö®-¡¾-¢º¤-®ðìò¦ñ©, -î-º½÷¨¾©- Íõ î-ê½®¼ê÷ì½-¡ò© ¢º¤-®ðìò¦ñ© (Background and experience of the Company, Licence or Business Registration
ofthe Company)
- ¦ñ¨¾»È¸´ê÷콡ò© (áðì½ó ´ó¦º¤®ðìò¦ñ©¢œÄ¯) (Shareholder’s Agreement
in case there are many Companies)
- î-´º®-¦ò© ùɰøɪ¾¤Îû¾-®ñ©¾-¢¾-¹÷É Íõ ®ðìò¦ñ©,Ã-¡ðì½ó -®÷¡£ö-©„¤¡È¾¸®Ò-µøÈ-Ã-ª¿-ÁÎȤ
¦ø¤-¦÷©-¢º¤-®ðìò¦ñ© (Attorney of power in case that person is not in the highest
positionof the Company)
- Á°-ê† ¥÷©¦½«¾-ê†-ª˜¤¢º¤-£¤¡¾- (Map of the Project location / Project Site)
- Àº¡½¦¾ ¡È¼¸¡ñ®-¢Ó-´ø-꾤-©É¾-Àªñ¡ò¡-¢º¤-£¤¡¾ (Technical Data of the Project)
- Àº¡½¦¾ ¡È¼¸¡ñ®¡¾ìö¤À¡ñ®¡¿¢Ó´øÀ®œº¤ªí¢º¤Â£¤¡¾ (Preliminary
Collecting Data of the Project.)
- ¥ö©Ï¾¨ -¦½Îñ®¦½Îø-¢º¤¦½-«¾-®ñ-¡¾-À¤ò Íõ ê½½-£¾ («É¾´ó)(Financial supported Documents of financial Institutions or Banks, if any)
- Àº¡½¦¾¡È¼¸¢Éº¤ºˆÅ(Others related Documents)
¢É¾²½À¥í¾ª¾¤Îɾùɮðìò¦ñ© ¢ð¨ˆ£¿»Éº¤¢ðìö¤êô´¾¨ñ¤êȾÀ²ˆº²ò¥¾ì½¾º½÷´ñ©¡¾ ìö¤êô©„¤ì÷È´š: (On behalf of theCompany I apply this application form for your consideration for investment approval as follow):
§ˆ°øɪ¾¤Îû¾-¢º¤®ðìò¦ñ© ꆨˆ£¿»Éº¤¢ðìö¤êô (Name of a person on behalf of the Company
(ies) apply this application form)
êȾ (Mr / Ms)...... ª¿-ÁÎȤ (Position) ......
®ðìò¦ñ© (Company) ………...... …………………
¸ñ-, À©õº, -¯óÀ¡ó© (Date of birth)...... ……………………………………......
¦½«¾-ê†-À¡ó© (Place of birth) ………………………………………………………….…
¦ñ§¾© (Nationality) ...... º¾§ó®(Occupation)......
ꆵøȮɾ (Home Address) ......
...... ….
-Âê콦ñ® (Telephone)……………………..-Âêì½-¦¾ (Facsimile)…………………….
Îñ¤¦õ°È¾Á©Àì¡êó (Passport No)...... -......
ºº¡Ã¹É¸ñêó(Date of Issue)......
ºº¡Ã¹Éê†(Place of Issue) ...... -......
¸ñêóÏö©º¾¨÷(Valid Until)......
Œ -À®ó-Âê콦ñ® ªò©-ªÒ µøÈ ¦¯¯ 쾸(Contact Number in Lao PDR) …..
…………………………………………………………………………………………
1. ¢Ó´ø¡È¼¸¡ñ® ®ðìò¦ñ© ê†-¦½-ÀÎóìö¤êô
(Information concerning companies)
-- Ã-¡ðì½ó-´ó-;¨-®ðìò¦ñ© ¦½-ÀÎó-ùÉ-¢¼ì¾¨-콺¼©-¢º¤-ÁªÈ-ì½-®ðìò¦ñ©
In case there are many Companies, please give details of each Company
1.1 §ˆ ®ðìò¦ñ© (Name of the Company) ......
......
Œ ¦½«¾-ê†-¥ö©-ê½®¼ (Place registered)……......
......
Œ ¸ñ, -À©õº, ¯ó ¥ö©-ê½®¼ (Date / Month / Year of registration):......
Œ êô-êñ¤-Ïö© (Total capital) -......
Œ êô-¥ö©-ê½®¼ (Registered capital) -......
Œ §ˆ ¯½ê¾ Íõ º¿¸¨-¡¾-ù¨È (Name of CEO/President/Chairman/Managing Director) -
êȾ- (Mr / Ms): ......
¦ñ§¾©-- (Nationality)...... ª¿-ÁÎȤ (Position)......
Œ ê†-ª˜¤¦¿ñ¡¤¾-ù¨È: (The Head Office is located at:) -......
......
......
Œ ¢½ÁΤê÷콡ò© (Business Sector) ......
......
......
-Œ 쾨콺¼©¢º¤¡ò©¥½¡¾ (Descriptions of Business Activities) ......
......
......
Œ -£¤¡¾-ù¨Èê†-²í-À©„ê†-Ä©É-¥ñ©ª˜¤¯½ªò®ñ©-¦¿-Àìñ©-´¾-Áìɸ (The main projects have been completed)......
......
......
1.2. §ˆ ®ðìò¦ñ©(Name of the Company) ......
......
Œ ¯½-Àê© -Áì½ ¦½«¾-ê†-¥ö©-ê½®¼ (Country and Place registered)……......
......
Œ ¸ñ, -À©õº, ¯ó ¥ö©-ê½®¼ (Date / Month / Year of registration):......
Œ êô-êñ¤-Ïö© (Total capital) -......
Œ êô-¥ö©-ê½®¼ (Registered capital) -......
Œ §ˆ ¯½ê¾ Íõ º¿¸¨-¡¾-ù¨È (Name of CEO/President/Chairman/Managing Director) -
êȾ (Mr / Ms)......
¦ñ§¾©-- (Nationality)...... ª¿-ÁÎȤ (Position) ......
Œ ê†-ª˜¤¦¿ñ¡¤¾-ù¨È:(The Head Office is located at:) -......
......
......
Œ ¢½ÁΤê÷콡ò© (Business Sector) ......
......
......
-Œ 쾨콺¼©¢º¤¡ò©¥½¡¾ ( Descriptions of Business Activities)......
......
......
Œ -£¤¡¾-ù¨Èê†-²í-À©„ê†-Ä©É-¥ñ©ª˜¤¯½ªò®ñ©-¦¿-Àìñ©-´¾-Áìɸ (The main projects have been completed) ......
......
......
2. ¢Ó´ø¡È¼¸¡ñ® -£¤¡¾ ꆦ½-ÀÎó ¢ð-ìö¤êô
(Information concerning the project to be applied for investing)
2.1 §ˆ -®ðìò¦ñ© ꆥ½ª˜¤¢œµøÈ ¦¯¯ 쾸 (The Name of the Company to be established in Lao
PDR) ......
2.2 ¯½-À²© -Áì½-»ø®-Á®®-¡¾-¦É¾¤ª˜¤(Type and Form of the establishment)
2.2.1. ¯½À²©¸ò¦¾¹½¡ò© (Type of Enterprise):
¸ò¦¾¹½¡ò©¦È¸®÷¡£ö (Private Enterprise)
ìñ©¸ò¦¾¹½¡ò© (State Enterprise)
¸ò¦¾¹½¡ò©¯½¦ö´ (Joint Venture Enterprise)
¸ò¦¾¹½¡ò©ì¸´ÏøÈ (Cooperative Enterprise)
2.2.2»ø®Á®®¸ò¦¾¹½¡ò©(Forms of Enterprise)
¸ò¦¾¹½¡ò©¦È¸®÷¡£ö (Individual Enterprise)
¸ò¦¾¹½¡ò©¹÷ɦȸ (Partnership Enterprise)
®ðìò¦ñ© (Company)
2.2.3.¯½À²©¢º¤¸ò¦¾¹½¡ò©¹÷ɦȸ (Kinds of Partnership)
¸ò¦¾¹½¡ò©¹÷ɦȸÁ®®¦¾´ñ (Ordinary Partnership)
®ðìò¦ñ© ¥¿¡ñ© (Limited Company)
2.2.4. ¯½À²© ®ðìò¦ñ©:
®ðìò¦ñ© ¥¿¡ñ© (Limited Company)
®ðìò¦ñ© ´½¹¾§ö (Public Company)
2.3. ¥÷©¯½¦ö¤¦½-ÀÎó¢ð§º¡£í Áì½ ¦¿Í¸©Á»È(Proposal for Prospecting and Exploration of ...………………………….……………………Mineral.
Œ ¦½«¾-ê†-ª˜¤¢º¤-£¤¡¾(Project Location):
®É¾ (Village)…………………… À´õº¤ (District)...... ……...
Á¢¸¤ (Province)...... ……...
Œ Àœºê†êñ¤Ïö© ¢ð§º¡£í Áì½ ¦¿Í¸© ¡òÂ쪾Á´ñ©/À»ñ¡ª¾, §‡¤´ó¥÷©²ò¡ñ©©„¤ì÷È´š:(Total Area for prospectingand Exploration: ...... ha/Km2),details as follows:
Œ ¥÷©²ò¡ñ©(Co-ordinates)
A...... ……………………………………………
B...... ……………………………………………
C…...... ……………………………………………
D...... ……………………………………………
3. £¾©£½À¡¾ìö¤êô(Estimate on Investment)
Œ êôêñ¤Ïö©(Total Capital):...... US$
Œ êô¥ö©ê½®¼ (Registered Capital) ...... US$
(êô¥ö©ê½®¼®ÒùÉÍЩ 30 % ¢º¤êôêñ¤Ïö©Registered Capital not less than 30% of the
total capital)
Œ §ñ®¦ò£ö¤ê† (Fixed Assets):...... US$
Œ §ñ®¦òÏø¸¼(Curent Assets): ...... US$
4. £¾©£½À£È¾Ã§É¥È¾¨Ã¡¾ìö¤êô(Estimate on Expenditure)
ŒÄ쨽§º¡£í (Prospecting Period):...... US$
ŒÄ쨽¦¿Í¸© (Exploration Period):...... US$
ŒÄ쨽¦É¾¤®ö©¸ò²¾¡À¦©«½¡ò©(FS Period):...... US$
Œ £È¾Ã§É¥È¾¨Ã¡¾®ðìò¹¾Â£¤¡¾ (Admin Expenditure):...... US$
Œ £È¾Ã§É¥È¾¨ºˆÅ (Others Expenditure) ...... US$
5.ÁÍȤêô ê†-¥½-´¾-²ñ©ê½¾-£¤¡¾ (Source of financing for developing the project):
+ êô´ó-Àº¤ (Own equity) ...... % ( ...... US$)
+ êô-¡øÉ-µõ´ (Loan) ……………………...………..% (……………...... US$)
6.ÁÍȤêôꆥ½Ã¹É¡¾¦½Îñ®¦½Îø Íõ £¸¾´-º¾©-¦¾´¾©ê¾¤-©É¾-¡¾-À¤ò ê†-¥½-´¾-²ñ©ê½¾-£¤¡¾Ã¹É-¦¿-Àìñ©-°ö (Source of financing supported /or financial capability tosuccessfully undertaking the Project):
§ˆ-¦½-«¾-®ñ-¡¾-À¤ò Íõ ê½½-£¾ ê†-¥½Ã¹É¡¾-¦½Îñ®¦½Îø («É¾-´ó)(Name of the Financial Institutionsor Banks, if any): ......
………………………………………………………………………………………….....
7. ¡¿ö©À¸ì¾Ã¡¾§º¡£í, ¦¿Í¸© Áì½ ¦É¾¤®ö©¸ò²¾¡À¦©«½¡ò©ŒÀªñ¡ò¡
(Prospecting, Exploration and Feasibility Study Period)
Œ Ä쨽§º¡£í (Prospecting Period) ...... À©õº/¯ó (Month/Year)
Œ Ä쨽¦¿Í¸© (Exploration Period) ...... À©õº/¯ó (Month/Year)
Œ Ä쨽¦É¾¤®ö©¸ò²¾¡À¦©«½¡ò© (FS Period) ...... À©õº/¯ó (Month/Year)
8. ¸ò§¾¡¾©É¾®ÒÁ»È ꆥ½´¾¯½ªò®ñ©Â£¤¡¾(Mining Technical Staff of the
Project)
8.1.§ˆ Áì½ ¾´¦½¡÷ (Name and surname) …………………………………………….. ¸ñ-, À©õº,-¯óÀ¡ó© (Date of birth)…………………......
¦ñ§¾© (Nationality) ...... º¾§ó®(Occupation)...... ¸ò§¾»¼ (Field of Study) ……………………………………………………………….
8.2.§ˆ Áì½ ¾´¦½¡÷ (Name and surname) …………………………………………….. ¸ñ-, À©õº,- ¯óÀ¡ó© (Date of birth)…………………......
¦ñ§¾© (Nationality) ...... º¾§ó® (Occupation)...... ¸ò§¾»¼ (Field of Study) ……………………………………………………………….
8.3.§ˆ Áì½ ¾´¦½¡÷ (Name and surname) …………………………………………….. ¸ñ-, À©õº,- ¯óÀ¡ó© (Date of birth)…………………......
¦ñ§¾© (Nationality) ...... º¾§ó® (Occupation)...... ¸ò§¾»¼ (Field of Study) ……………………………………………………………….
Ͼ¨-À¹©:¡½ì÷¾£ñ©-ªò©-Àº¡½¦¾ê†-¡È¼¸¢Éº¤¢É¾¤-Àêò¤-š´¾-²Éº´ -À§„: ¡¾© -Áì½ ¯½¦ö®-¡¾-à ¡¾À»ñ©¸¼¡¤¾.
Note:(Please attach any related document(s) mentioned above such as the Certificate andexperiences)
9. ®ö©®ñêô¡¡¾ìö¤À¡ñ®¡¿¢Ó´øÀ®œº¤ªíµøÈ¥÷©Â£¤¡¾ª˜¤µøÈ (Preliminary
CollectingData at the Project Site)
Œ (Àº¡½¦¾£ñ©ªò© ¡)
(Annex A)
10. ®ö©ì¾¨¤¾¡È¼¸¡ñ®°ö¡¾À¡ñ®¡¿¢Ó´øÀ®œº¤ªí(Preliminary Report on
Prospecting and Exploration)
Œ (Àº¡½¦¾£ñ©ªò© ¢)
(Annex B)
11. Á°©¿À󡾧º¡£í Áì½ ¦¿Í¸©(Prospecting and Exploration Plan)
Œ (Àº¡½¦¾£ñ©ªò© £)
(Annex C)
12. «É¾---£¤¡¾-´ó-£¸¾´-À¯ñ-į-Ä©É-Ã-¡¾-²ñ©ê½¾ ®ðìò¦ñ©-À¯ó©-º¡¾©-ùÉ- ìñ©«½®¾ -«õ-¹÷É µÈ¾¤Îûº¨...... % (...... - À¯ó-À§ñ) ¢º¤¡¾¯½¡º®¹÷Éêñ¤Ïö© ¢º¤Â£¤¡¾:
(If the Project is feasible for development, the Company opens for the Government of Laos to have equity at least ……..% (………… percent) of the total equity for the project).
13. £¸¾-´¦¾´¾©-Ã-¡¾¥ñ©-¦ñ Áì½ §º¡-ÁÍȤêô§¸È¨ÀÍõºÁ¡È ìñ©«½®¾ì¾¸ -©¨-®ðìò¦ñ©:
Ability to arrange and source for the target equity of the Government of Lao by the Company:
--´ó-£¸¾´-¦¾´¾© ...... % ( ...... À¯ó-À§ñ) ¢º¤¡¾¯½¡º®¹÷Éêñ¤Ïö© ¢º¤Â£¤¡¾.(Ability to arrange and source for the target equity of the Government of Lao at least …….. % (………….percent) of the total equity for the Project).
-®Ò´ó-£¸¾´-¦¾´¾© (No ability to provide)
--¢É¾-²½-À¥í¾ ¢ð-µ˜¤-µõ-¸È¾-ê÷¡-¢Ó-£¸¾´ Áì½ ¢Ó-´ø-ªÈ¾¤Å-ê†-Ä©É-ì½-®÷-´¾-¢É¾¤-Àêò¤-˜ Á´È-«õ¡ªÉº¤- Áì½À¯-ñ-¡¾-£¾©-£½-À-ê†-áÉ-£-¼¤-¡ñ®-£¸¾´-À¯ñ-¥ò¤-ê÷¡-µÈ¾¤.
(I certify that the statements made by me in this form are true, complete and correct to the best of my knowledge.)
¦½-˜, ¢É¾-²½-À¥í¾-¥‡¤-»¼-¦½-ÀÎó-´¾-¨ñ¤-êȾ À²ˆº²ò-¥¾-ì½-¾-ª¾´-ê†-À¹ñ-¦ö´£¸-©É¸¨.
(Your consideration and approval will be highly appreciated)
©É¸¨-£¸¾-´-ñ®-«õ-µÈ¾¤-¦ø¤,
Yours sincerely,
¸ñ-êó/date,..-..-..-..-..-..-..-..-..-..-..-..-..-..-..-..-..-..-..-..
쾨-À§ñ- Áì½ §ˆ-Á¥É¤/signature and full name