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Clarence Campeau Development Fund APPLICATION FOR EQUITY CONTRIBUTION Name of Applicant: Trade Name of Business: Your Business is: ¨ A Proprietorship ¨ A Partnership ¨ An Incorporated Company Business Phone No.: What Type of Business Is This: Mailing Address: City/Town Postal Code Amount Being Applied Reason You Are Applying For This Contribution: For: $ BELOW PLEASE INDICATE WHAT YOUR PROJECT COSTS WILL BE AND THE AMOUNT OF FINANCING REQUIRED PROJECT COSTS: FINANCING: Land and Buildings $ CCDF $ Machinery & Equipment Bank/Credit Union Vehicles Cash Equity Leasehold Improvements Other (specify) Working Capital Administration Fee (1% of Contribution Request) Other (specify) TOTAL $ = TOTAL $ Names of Owners of the Business: Position Held: % Owned MNS Membership No. (Attach copy of Membership Card to Application Form) Name of Your Business's Bank: Branch Address: Phone Number: Existing Limit on Operating Line of Credit: $ OUTLINE EXISTING BUSINESS LOANS: Name of Lender Original Amount Due Date Present Amount Due Interest Rate Repayment Terms Security Given $ $ % Name of Lender Original Amount Due Date Present Amount Due Interest Rate Repayment Terms Security Given $ $ % ADMINISTRATION FEE: The Fund will be charging an administration fee 1% of the approved contribution to cover the initial expense for preparation and security documentation. CREDIT INFORMATION: The Applicant hereby grants the Clarence Campeau Development Fund the authority to conduct any credit checks, inquiries and property searches from other agencies and sources it deems necessary to reach a decision on this application or necessary to administer the loan and consents to the disclosure at any time of any credit information about the applicant to any credit reporting agency or to anyone whom I/we have financial relations. RIGHT TO PUBLICIZE: The applicant hereby grants the Clarence Campeau Development Fund the right to make public announcements related to the funding granted, to erect signs or other notices on the site of projects involving construction or expansion of an existing enterprise, and in general may publicize or advertise any details related to the funding granted. DECLARATION: The statements and information herein and those attached which form part of this application are for the express purpose of obtaining financial assistance from the Clarence Campeau Development Fund and are to the best of my/our knowledge and belief, true and correct. The Applicant hereby declares that none of the principals or guarantors are undischarged bankrupts or have any bankruptcy proceedings in existence with respect to themselves or companies which they operate. The Applicant hereby further declares that he/she is not associated (that is an officer or director, or spouse or child of an officer or director) with the CCDF or the Metis Society of Saskatchewan. The Applicant hereby declares that he/she is of Métis ancestry. DATE Applicant/Company ___________________________ Authorized Signature Seal (if applicable) *Please Note: A Personal Statement must be provided with this application for each owner of the Business and any Guarantors Please attach a copy of your Metis Nation of Saskatchewan membership card or other proof of Metis ancestry to your application form.