Meristem Finance Corporate Lease Form – Meristem Securities Ltd

Step 1 of 2

Company Name *

Address of Company *

Address Line 1

City

State / Province / Region

TITLE HELD IN BUSINESS *

Telephone *

Mobile *

Fax:

Company’s Principal Business *

Years in Business

Type of Company

Ownership Structure

Company Size (Number of current staff)

Is the Company quoted on Nigeria Stock Exchange

Principal Shareholders:

Enter a comma separated list of shareholders and their percentage ownership e.g David Omole (34%)

DIRECTOR PROFILE

Enter a comma separated list of Directors Full name, professional qualifications ,country of origin and years of experience e.g Wole Sodemade CFA Nigeria 17 years

SENIOR MANAGEMENT

Enter a comma separated list of senior managers and their respective designation e.g Felix Usifo Ceo,

Company Contact Name

for Monitoring and Managing Transaction

Company Contact Phone

FINANCIAL INFORMATION

Company Auditors

Auditors Telephone

Address of Auditors

Address Line 1

City

State

Company Principal Bank(1)

Bank Address

Bank Contact

Contact Telephone

Company Principal Bank(2)

Bank Address

Bank Contact

Contact Telephone

Have They Extended Any Credit Facilities to The Company

Proposed Tenor *

TRANSACTION DETAILS

Description (Equipment Specification)

Equipment Price

Percentage Company Would Finance

Preferred Length of Facility

Preferred Type of Rental

DECLARATION

I *

First

Middle

Last

of the above information hereby undertake to repay /liquidate the loan facility of

Company Name

Signature *