Investor Loan Application Form

INVESTOR LOAN APPLICATION FORM

Application Date:   Reference Number (internal):

Applicant Information

Entity Type: Individual Corporation LLC Trust Partnership Other:

Business & Financial Background

Years in Operation:   Employees:   Annual Revenue:

Loan Request Details

Requested Principal Amount: $   Proposed Interest Rate (annual %):

Proposed Term:   Desired Funding Date:

Loan Structure Desired: Secured Unsecured Convertible Subordinated

Will a personal guaranty be provided if requested? Yes No

Bank & Credit References

Financial Documents & Attachments

Please indicate which documents are attached: Financial statements (audited or reviewed) Federal tax returns (last 2 years) Capitalization table

Certifications, Authorizations & Representations

The undersigned certifies that all information provided in this application and in supporting documents is true, complete and correct to the best of the applicant's knowledge. Applicant authorizes the investor and its agents to verify any information supplied, to obtain credit reports and to contact banks, trade creditors and references listed herein. Applicant acknowledges that knowingly submitting false information for the purpose of obtaining financing may constitute fraud and may result in civil and criminal penalties.

Applicant further represents that no litigation, judgment, lien or material adverse claim exists against the applicant except as disclosed in writing with this application. Applicant agrees to provide additional documentation reasonably requested by the investor to evaluate creditworthiness and to execute additional agreements (including security agreements and guaranties) as a condition to funding.

By checking the box below, the applicant consents to the use and disclosure of the information provided in this application for the purpose of evaluating the loan request and administering any loan that may be extended.

I consent to credit checks, background verification and the use of supplied information as described above.

WARNING: Intentional misstatement or omission of material facts may constitute fraud and may be punishable by law.

Acknowledgement

Applicant acknowledges that this application is a request for consideration and does not constitute an offer, commitment or approval to extend credit. Any loan commitment will be subject to satisfactory due diligence, execution of definitive loan documents and any required security filings. The investor reserves the right to accept or decline applications in its sole discretion.

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