WEST AFRICA VENTURE FUND LLC
www.wavfonline.com
INVESTMENT APPLICATION FORM
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Please read the entire form before filling
Fill it in completely, type if possible
If the available space is insufficient, make use of extra page(s)
Information provided is for the use of WAVF LLC only and will be treated strictly
confidential.
WAVF LLC reserves the right to reject any application if the information submitted
is seen to be false or incomplete.
SECTION I:
THE CHIEF PROMOTER
1.1
Full Name:
1.2
Addresses of Chief Promoter:
Office:
Tel:
Residential:
Tel:
E-mail:
1.3
Chief Promoter’s Educational Qualification with Dates:
1.4
Chief Promoter’s Age:
1.5
Marital Status:
Nationality:
Name of Spouse:
CONFIDENTIAL
1.6 FINANCIAL STATUS
1.6.1 Names and Addresses of Chief Promoter’s bankers with Account Numbers:
[a]
[b]
[c]
1.6.2 Are you or any other Director(s) indebted to anybody, bank or any other
institution?
Yes
No
1.6.3 If yes, please state:
Date
Source
Amount(N)
Purpose
Duration Date Due
Balance
a
b
c
d
e
1.6.4 Did you guarantee any outstanding loans for other persons/companies?
Yes
No
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CONFIDENTIAL
1.6.5 If yes, please state:
Beneficiary
Lending Bank/
Institution
Loan Amount
Outstanding
Amount
Guaranteed
Repayment
to date
Balance
i
ii
iii
iv
v
Please attach: (a)
(b)
(c)
Two passport photographs each of the lead promoter(s) of the venture.
Personal financial statement of principal promoters indicating assets and ability to
meet the equity required contribution to the project.
Letter of Intent of Directors to personally guarantee loan request (when applicable)
SECTION 2
THE COMPANY
2.1
Full Name:
2.2
Registration No.:
2.3
Registered Address:
2.4
Postal/Business Address:
Reg. Date:
E-mail:
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CONFIDENTIAL
2.5
2.6
Status of Business:
(a)
Authorized Share Capital:
(b)
Paid-up Share Capital:
(c)
Company’s Objective:
Company’s Current Ownership Structure:
Name
Nationality
Share Capital
Contribution
%
FINANCIAL STATUS
2.7
Names and Addresses of Company’s Bankers with Account Numbers:
(a)
(b)
(c)
(d)
(e)
2.7.2 Is the company or any of its Director(s) indebted to anybody, bank or any
other institution?:
Yes
No
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CONFIDENTIAL
2.7.3 If yes, please state:
Date
Source
Amount(N) Purpose
Duration
Date Due
Balance
a
b
c
d
e
2.7.4 Did the company
persons/companies?
Yes
guarantee
any
outstanding
loans
for
other
No
2.7.5 If yes, please state:
Beneficiary
Lending Bank/ Loan Amount
Amount
Repayment
Institution
Outstanding Guaranteed
To Date
Balance
i
ii
iii
iv
v
Please attach (a)
(b)
(c)
(d)
Two copies each of Certificate of Registration, Article of Association,
Certified copies of forms C-02, C-06 and
C-07
Resolution of the Board of Directors of your company to do specified business
with WAVF LLC
Two copies of the company’s statement of affairs
The company’s audited account statement for the last three years(if any)
SECTION 3
THE PROJECT
3.1
Title of Project:
3.2
Category of Project
3.3
Sector
3.4
Location of Project Site:
(Early Stage Financing, Expansion, Start-Up, Acquisition/MBO/ MBI Revitalization etc).
(Food Chemical, Electrical, Pharmaceutical, Pulp & Paper, Textile, Plastics etc)
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CONFIDENTIAL
3.5
Local Government Area:
3.6
State name and distance of the nearest commercial town to project site:
3.7
Brief description of proposed project:
3.8
Proposed Technology:
3.9
Company’s experience in type of project proposed:
3.10
Size and capacity of project:
3.11
Briefly assess the strengths, weaknesses and major risks of the proposed
project:
(a)
Strengths:
(b)
Weaknesses:
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CONFIDENTIAL
(c)
Major Risk(s) of the Venture:
3.12
If the project is existing, briefly give particulars of the key management staff
below:
(a)
Name:
Position:
Age:
Marital Status:
Qualification and Experience:
(b)
Name:
Position:
Age:
Marital Status:
Qualification and Experience:
(c)
Name:
Position:
Age:
Marital Status:
Qualification and Experience:
*Attach one copy each of their CVs.
3.13
Assess the management skill presently available to the project:
Marketing:
Finance:
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CONFIDENTIAL
Operations:
3.14
Other business activities undertaken by the company:
3.2 FINANCIAL PARTICULARS OF PROJECT
3.2.1. Project Cost:
Existing
Proposed
Land:
Building & Infrastructure:
Plant & Machinery:
Total Fixed Assets
Vehicles:
Furniture Fittings & Equipment:
Pre-operational Expenses:
Working Capital:
Total Base Cost
Contingency:
Total Cost of Project:
3.2.2 Project Financing Plan:
Loans (long/medium term)
Loans (short term-OD’s etc)
Credit(s)
Equity
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CONFIDENTIAL
3.2.3 How much of this do you require from WAVF LLC?
As Loan:
As Equity:
Total:
3.2.4 Who finances the difference?
3.2.5 Sources of Finance:
Please attach (a)
(b)
(c)
(d)
(e)
(f)
Statutory certificate of occupancy of the project site (where applicable)
Approved project site plan, building plan etc.
Bill of quantities of civil works
Technical valuation report on present state of plant and machinery, factory
equipment and buildings (if existing).
At least three quotations for proposed plant and machinery
Business plan of project (2 copies)
SECTION 4
SECURITY (Where Applicable)
4.1
List property items which you are willing to offer as security for the loan
aspect of your application:
Property
Location
Year
Estimated
Acquired or present cost of
built
property
Is it
Encumbered
i
ii
iii
iv
v
4.2
Guarantees:
Give names and addresses of proposed guarantors (forms are enclosed for guarantors to
fill and return to the company)
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CONFIDENTIAL
Others
List other things you may want to offer as security (e.g. Life Insurance Policies, Share Certificates etc.):
*Each of these should be accompanied by their title documents e.g. CERTIFICATE OF OCCUPANCY, REGISTERED DEED OF CONVEYANCE,
SURVEY PLANS, SKETCH PLAN OF LOCAL GOVERNMENTS SHOULD BE ATTESTED BEFORE A MAGISTRATE.
SECTION 5
DECLARATION
I declare that the above statements are correct to the best of my/our knowledge and that I/we
have not concealed any material facts from WAVF LLC.
FULL NAME IN BLOCK LETTERS:
POSITION:
SIGNATURE:
DATE:
FULL NAME IN BLOCK LETTERS:
POSITION:
SIGNATURE:
DATE:
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CONFIDENTIAL
WEST AFRICA VENTURE FUND LLC
www.wavfonline.com
.
TO WHOM IT MAY CONCERN
AUTHORITY TO RELEASE INFORMATION
I…………………………………………………………………………………………of…………………………………………
..………………………………………………………………………………………………… having applied to West
African Venture Fund LLC, 13 Lamina Sankoh Street, Freetown, Sierra Leone for Equity
Participation/Loan Facility, hereby authorise you to release information about my person, my
business interest(s), and/or my Bank Account as the West African Venture Fund LLC may
require.
This authority is freely given by me.
Signature
Date
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CONFIDENTIAL
GUARANTOR’S FORM
The Country Manager
West African Venture Fund LLC
13, Lamina Sankoh Street
Freetown, Sierra Leone
Sir,
I…………………………………………………………………………………………………....having been proposed
by……………………………………………………………………………as a guarantor for an Equity
Investment Loan of $…………………………..do hereby give my consent. I submit hereunder the
following information about myself.
1.
Present Occupation and Employer
2.
Annual Income: $
3.
Amount willing to guarantee: $
4.
Name and Address of Banker(s) with Account Numbers:
5.
Property willing to pledge to support my guarantee:-
Each of the properties should be accompanied by their title documents e.g. CERTIFICATE OF OCCUPANCY, REGISTERED DEED OF
CONVEYANCE, SURVEY PLANS, SKETCH PLAN OF LOCAL GOVERNMENTS SHOULD BE ATTESTED BEFORE A MAGISTRATE).
(GUARANTOR’S SIGNATURE)
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CONFIDENTIAL
GUARANTOR’S FORM
The Country Manager
West African Venture Fund LLC
13, Lamina Sankoh Street
Freetown, Sierra Leone
Sir,
I…………………………………………………………………………………………………....having been proposed
by……………………………………………………………………………as a guarantor for an Equity
Investment Loan of $…………………………..do hereby give my consent. I submit hereunder the
following information about myself.
1.
Present Occupation and Employer
2.
Annual Income: $
3.
Amount willing to guarantee: $
4.
Name and Address of Banker(s) with Account Numbers:
5.
Property willing to pledge to support my guarantee:-
Each of the properties should be accompanied by their title documents e.g. CERTIFICATE OF OCCUPANCY, REGISTERED DEED OF
CONVEYANCE, SURVEY PLANS, SKETCH PLAN OF LOCAL GOVERNMENTS SHOULD BE ATTESTED BEFORE A MAGISTRATE).
(GUARANTOR’S SIGNATURE)
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