UNIVERSAL CONNECTION INC.
Holder Name :__________________________________________________________
Signatory Name: _________________________________________________________
E-Mail Address: _____________________________________________
Phone: ____________
Requested Loan Amount: $ _________________
Desired Loan Term: ___3 yr ___ 5 yr ___7 yr ___10 yr
Financial Instrument to Pledge
Debenture Type________________
Issuing Bank____________________
Date of issuance_________________
Maturity Date____________________
Face Value______________________
Currency________________________
Market Value____________________
Denomination Break down__________
Coupon_________________________
Collateral Type___________________
CUSIP__________________________
ISIN____________________________
Registered Clearing________________
Bank Deposited ________________________________
Bank Address __________________________________
Account Number________________________________
Bank Officer Name______________________________
Telephone_____________________________________
I, ____________________,OWNER/BENEFICIARY, holder of Passport No. ____________________, issued (Date) ____________________, by (Country), expiration date ____________________, with full responsibility and under penalty of perjury and duly authorized, hereby authorize the lender/funder to verify the asset(s) on deposits at _______________ bank, Account number________, Instrument Number_____________________,
X________________________
Holder (Authorized Signatory) COMPANY SEAL
Company
Title
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