STENN INTERNATIONAL LTD.

CONFIDENTIAL APPLICATION AND INFORMATION REQUEST

Company Legal Name: ________________________________ Registration #: _____________________

Registered Address:_____________________________________________________________________

Contact Person: _________________________ Title: _____________________________

Phone: ___________________ Email: ______________________ Website: ________________________

Company Summary

Description of Business:
_____________________________________________________________________________________
_____________________________________________________________________________________

Last year’s sales: _____________ Prior year’s sales: ____________ Sales year to date: _____________

Projected sales (next 12 months): _______________

Number of customers: ___ Current AR Outstanding: __________ Current AP Outstanding: _________

Bad Debt (last 12 months): ___________ Dilution (Chargeback, returns, etc.) %: _____

Shareholders:

Full Name: _____________________________________________ % Ownership: ________

Citizenship: _____________________________ ID # _______________________________

Full Name: _____________________________________________ % Ownership: ________

Citizenship: _____________________________ ID # _______________________________

Full Name: _____________________________________________ % Ownership: ________

Citizenship: _____________________________ ID # _______________________________

Please use an additional page if necessary

Company Officers:

Full Name: ___________________________________ Title: __________________________

Full Name: ___________________________________ Title: __________________________

Full Name: ___________________________________ Title: __________________________

Please use an additional page if necessary

STENN INTERNATIONAL LTD.
CONFIDENTIAL APPLICATION AND INFORMATION REQUEST

Company Attorney:

Name: ______________________ Phone: ___________________ Email: ______________________

Company Accountant:

Name: ______________________ Phone: ___________________ Email: ______________________

Existing Financing Relationships:

Bank/Lender: ________________ Type: ____________ Outstanding Balance: _________________

Assets encumbered (pledged): ________________________

Existing Financing Relationships:

Bank/Lender: ________________ Type: ____________ Outstanding Balance: _________________

Assets encumbered (pledged): ________________________

Please use an additional page if necessary

Please provide the following:

-Income Statement and Balance Sheet for the two prior years and year to date

- Current Accounts Receivable and Accounts Payable Aging Report

-Customer List (template provided)

_____________________________________________________________________________________

The undersigned submits this Application to provide information necessary and to be related upon in
assessing the potential of a commercial financing relationship, and states all information contained
herein is true and accurate. The undersigned authorizes Stenn International and/or its affiliates to
investigate all information provided herein and any additional documentation supplied to Stenn, and
Stenn is hereby authorized to check the credit and financial background of the company, and the
owners and officers. A photocopy, including fax copy, may be accepted as an original.

Full Name: ________________________ Title: ____________________

Signature: __________________________ Date: ___________________