Priority Capital Inc.

Tel:

416-880-1397

Fax:

416-880-1397

Email:

Web:

Address:

505 Consumers Road Suite 707 Toronto, Ontario M2J 4V8

BUSINESS FACILITY APPLICATION

Financing Requested:
Bank Security/ Collateral Pledged:
Accounts Receivable: Pledged as security elsewhere?

ASSETS

LIABILITIES

Real Estate details - Address

Valued at as

Are there any other important facts or information not disclosed in this application that might in any way affect your credit which you believe or know to be relevant and should be considered:

Do you have other information? *

SUPPORTING DOCUMENT CHECKLIST

Financial Statements Please include Balance Sheets, Income Statement, Trial Balance and Notes 12 month Sales and Cash Flow Forecast (if applicable) Annual Statements: 1 Year Interim Statements: Most Current
Accounts Receivable and Accounts Payable Aged Summary
Bank Statements Last 3 Months
Articles of Incorporation and Amalgamation/ Business Names Registrations First 2 pages only
Inventory Summary As Applicable
Financing Letters (From existing bank and fixed assets lenders, including any revision) As Applicable
Tax Return Showing SR&ED Tax Credit Claim Amounts (federal and provincial) SR&ED Financing only

CERTIFICATION

I hereby certify that the information provided in this personal statement is true, accurate and complete. Permission is hereby granted for a confidential credit investigation. A copy of this form shall be good and sufficient authority for anyone having confidential or other information about the financial position of the APPLICANT herein to disclose such information to PRIORITY CAPITAL INC. ("PCI") upon request.

If representations are subsequently found to be incorrect or incomplete, PCI reserve the right to reject this application and cancel any contract that may be negotiable and shall not be obliged to fulfil any agreement with the APPLICANT, verbal or written. APPLICANT agrees that any expenses incurred by PCI , because of reliance by it upon incomplete or incorrect  statements made by the APPLICANT herein are chargeable to the APPLICANT.