Once we receive your information, we will
contact you to acknowledge receipt, and we should be able to provide an
Indication or Term sheet within two to three business days.
I am interested in:
Securities – Based Loan
Securities – Based Line of Credit
Both
NameCompany NamAddressPhoneE-mail
The securities and/or shares you wish to use as collateral for your loan will need to be in your new solely – owned brokerage or custodial account at a major, fully licensed bank, or major brokerage firm that will provide your financing. This will be done for you by your lending institution with your permission. Are you willing to move your collateral to your new lending brokerage?
Yes
No
Is Applicant a Current Shareholder?
Yes
No
If “Yes,” Type Percentage of OwnershipIf a portion, what is the maximum number of shares are you willing to use as collateral?When was the security (s) acquired?
Is the stock Free – Trading?
Yes
No
Is the stock restricted?
Yes
No
If “Yes,” Explain WhyWhen does the Restriction Expire?What is the purpose for this financing – how will the funds be used? Are you an employee, director, insider, or owner of 5% or more of any of the securities being pledged? If yes, please provide details.Are any of your securities currently in Certificate (“Cert”) form or Electronic Form…Please note, only Electronic Form Securities can be used for this transaction…if Securities are only in Certificate Form they will have to be converted to an Electronic Form.Are the securities you will be using for the Stock Loan or Credit Line all free trading – e.g., no liens or restrictions of which you are aware? If not, please provide details.Are any of your securities currently being used as collateral for a loan? If yes, please explain.Are there currently any third-party claims to any of your securities? (i.e., tax liens, divorce settlements, etc) If yes, please explain.Do you have your most recent stock account statement and if so, please send a copy back with this application?Are your securities part of an IRA or Keogh plan? If yes, they cannot be used for this financing program.What Exchange(s) Are Your Stocks Currently Being Actively Traded On?What is the current daily volume?What are the shares currently trading at?Total Value of Securities:Requested Loan Amount:Requested Loan Terms:
Are you the legal owner of these shares, or do you have power of attorney over them?
Legal Owner
Power of Attorney Signatory Owner
I am a Stock Loan Broker
Other
Have you had a past foreclosure / bankruptcy?
Yes – More Than 10 Years Ago
Yes – Less Than 10 Years Ago
No – Never
Securities Name - (Please list the stock names and stock symbols of all securities you wish to use for this transaction).What are the names of your Stock Trading Pages?Total Number of Shares or Description:Full Name of how securities are Held? (Trust, Individual, Etc…):Location of Security (s) (Name of Bank, Brokerage, etc.):Contact Person’s Details(Name, Phone, Email)Transfer Agent Details(Name, Phone, Email)
Who will be signatory if this is a credit line account?
I will be the sole signatory to this account.
I and other family members will be signatories to this account.
I and a non-family partner(s) will be signatory to this account.
An LLC or Corporation will be signatory to this account.
A Trust will be signatory to this account.
Please provide a current stock brokerage statement and a recent photo ID.
