Caribbean Disaster
Mitigation Project |
All information given in this form will be held in the strictest confidence.
NAME: ________________________________
APPLICANT NO: _____________________________________
ADDRESS: __________________________________________
TEL NO. (H) __________________ (W) ___________________
SEX: M / F
AGE: _____________________
MARITAL STATUS: M / S / D / P
CONTACT ADDRESS: _________________________________
NO. OF DEPENDANTS: ________________________________
EDUCATIONAL BACKGROUND: ________________________
MAIN EMPLOYMENT: _________________________________
INCOME (P/M): _______________________________________
PLACE OF EMPLOYMENT: _____________________________
OTHER EMPLOYMENT: ________________________________
INCOME (P/M): _______________________________________
STATEMENT OF AFFAIRSAssets | Liabilities |
Bank Accounts:
|
Bank Loans:
|
Land/Building:
|
Other Loans:
|
Vehicle:
|
|
Other:
|
Other:
|
Total Assets:
|
Total Liabilities:
|
Have you applied to ___________ before? Yes / No / Result: ___________________
Date of previous application _________________________
If rejected, reason ______________________________________________________
How did you find out about this loan program: ______________________________________________
Location: N / S / E / W / NE / SE / NW / SW
Area: Rural / Urban
Status of ownership of
(1)Building ______________________________
(2 ) Land _______________________________
If lease hold for any of the above, then a copy of the lease agreement must be submitted along with written permission from the Landlord to carry out the stated repairs.
Loan Amount requested: $_____________________
Purpose of Loan Request | Details |
Purchase of material: | |
Payment of labour: | |
Transportation: | |
Other: ________________________ | |
Total Request: |
Initial Funding for construction of building | __________________ |
Other Sources of Funding | __________________ |
Amounts outstanding from ( 1 ) and ( 2 ) above | $ _________________ |
Is Certificate of Title to Property available? Yes / No
What is the value of the property: $ ____________________________
Note: All applications must be accompanied by Bill of Quantities certified by an estimator recognized by __________________ as having the authority to do so.
Security Offered | Value |
Total value of securities |
Method of Repayment:
( 1 ) Salary Reduction ( Self )
( 2 ) Salary Deduction Guarantor
( 3 ) Authorization on Crop Sales
( 4 ) Other Sales
( 5 ) Over the Counter
I hereby certify that all the information given in this document is true and correct and that I have not held back any information which would negatively effect the decision to make the loan.
I further agree that as a condition of approval of the loan, that loan agency officers or anyone authorized by the loan agency Director will be allowed to inspect my premises at any reasonable time, during the renovation/operation, to obtain relevant information re the use of loan funds and compliance with the loan agreement.
Signed this ____ day of _____________, 20__
_________________________________________ | _________________________________________ |
SIGNATURE OF APPLICANT | SIGNATURE OF OFFICER |
CDMP home page: http://www.oas.org/en/cdmp/ | Project Contacts | Page Last Updated: 20 April 2001 |