Universal Connection Inc.
Name: ____________________________________________________
E-Mail Address: _____________________________________________
Phone: ____________
Requested Loan Amount: $ _________________
Desired Loan Term: ___3 yr ___ 5 yr ___7 yr ___10 yr
Eligible Securities to Pledge
Number of Shares: _____________
Name of Securities: __________________________________
Approximate Value of Each Share: $ _____________________
Stock Symbol (if known): ______________________________
Number of Shares: _____________
Name of Securities: __________________________________
Approximate Value of Each Share: $ _____________________
Stock Symbol (if known): ______________________________
Number of Shares: _____________
Name of Securities: __________________________________
Approximate Value of Each Share: $ _____________________
Stock Symbol (if known): ______________________________
Please Fax 206-666-4861
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