SHELTER AFRIQUE :- Borrower Information

Borrower Information (to be completed by the borrower)

NB: Any information provided herein will be used solely for the purpose of evaluating the borrower’s application for a loan from Shelter Afrique and shall not be disclosed to third parties without the express permission of the applicant

Customer Details (must be a company, society, cooperative or any such entity)

Name:
Address:
Date of Registration
Registration No.
Registered Address of Borrower
Physical Address of the Borrower (if different from above)

Directors (indicate names and addresses)

Name	Profession	Address	Year Appointed
1.

3. Shareholders Details

Name	Type (private or public)	Address	Profession/business	Holding

Where shareholders are institutions, applicants will be required to provide detailed information on the shareholders as if they were individuals.

4. Key Management Position

Position	Qualification/Experience	No. of years with company	Personal Physical Address
Managing Director
Director of Finance
Technical Director
Marketing Director
Company Secretary

Service Providers

Lawyers

Name:
Address:
Tel/Fax/Email
Physical Address

Auditors/Accountants

Name:
Address:
Tel/Fax/Email
Physical Address

Bankers

Name:
Address:
Tel/Fax/Email
Physical Address

Technical Advisers

Architects

Name:
Address:
Tel/Fax/Email
Physical Address

Civil/Structural Engineers

Name:
Address:
Tel/Fax/Email
Physical Address

Quantity Surveyors

Name:
Address:
Tel/Fax/Email
Physical Address

Services Engineers

Name:
Address:
Tel/Fax/Email
Physical Address

Project Managers

Name:
Address:
Tel/Fax/Email
Physical Address

Financial Information

End of Financial Year
Audited Accounts
Total Assets
Total Liabilities
Gross Revenue for last 3 years
Net Profit for last 3 years

Past Credit Performance

Have you borrowed before?
No. and total sum of loans borrowed (local currency or US$)
Last Amount Borrowed(local currency or US$)
Year of last loan signed
Bank (Lender)
Loan Balance, if any
Security for the loan

Tax/Fiscal Information

Tax Year/ Date Last Tax due for Payment
Last Tax Paid (attach receipt) US$ or local currency
Tax Due
Is Tax Clear a requirement? If yes attach copy
Bank (Lender)
Name of Tax Consultant
Address of Tax Consultant

Litigation

Has the Company been involved in any litigation with lenders or others in its course of business? If yes provide details

Declaration

I hereby declare that I have personally verified the information provided herein and to the best of my knowledge believe that it is accurate.

Name and Title of Person

Signature

Date