SIP Definitive Application for Guarantee



|[pic] |Multilateral Investment Guarantee Agency |

| |SIP Application For Guarantee |

| | |

| |[pic] |

| | |

| |Please send your completed form and all necessary documentation to migainquiry@. Within one week of |

| |filing this electronic SIP Application, please also send MIGA a signed copy of the signature page, by mail or by fax |

| |to: |

| | |

| |MIGA - Applications, Room U12-1205, |

| |1818 H Street, N.W., Washington, D.C. 20433, USA; |

| |Fax no: (1) (202) 522 26 30 |

| | |

| |Please complete all fields. If you are unable to provide all information, please fill out section 1 of the SIP |

| |Application form and MIGA will register the application. However, MIGA requires complete information in order to start|

| |processing and issuing a contract. |

| |

|1. |GENERAL INFORMATION |

| |INVESTOR |

|  |

|1.1 |Company's name |[pic] |

|  |Company's address |[pic] |

|  |  |[pic] |

| | |Country |

|  |  |[pic][pic][pic] |

| | |Telephone (country code-city code-telephone) |

|  |  |[pic][pic][pic] |

| | |Fax (country code-city code-fax) |

|  |  |[pic] |

| | |Email |

|  |

|1.2 |Size of Company (Average of last three years): |

| |  |

|  |Number of employees |[pic] |

|  |Size of assets |[pic] |[pic] [pic] |

|  |Annual revenues |[pic] |[pic] [pic] |

|  |

|1.3 |Investor country (where the company is |[pic] |

| |incorporated): | |

|  |

|1.4 |Contact person in company: |

| |Name |[pic] |[pic] |

| | |First |Last |

| |Title |[pic] |

|  |Address |[pic] |

|  |  |[pic] |

| | |Country |

|  |  |[pic][pic][pic] |

| | |Telephone (country code-city code-telephone) |

|  |  |[pic][pic][pic] |

| | |Fax (country code-city code-fax) |

|  |  |[pic] |

| | |Email |

| |INVESTMENT |

|  |

|1.5 |Host country (where |[pic] |

| |project is located) | |

| |  | |

|  |

|1.6 |Name of project |[pic] |

| |enterprise | |

|  |

|1.7 |Total amount of |[pic] [pic] |

| |investment at this time: | |

|  |Equity  |[pic] |

|  |Shareholder loans  |[pic] |

|  |Bank loans  |[pic] |

|  |Other  |[pic] Explain [pic] |

|  |TOTAL  |[pic] |

|  |

|1.8 |Brief description of project |

|  | |

|  |

|1.9 |Is your investment defined as |

| |  |

|  | [pic]New (i.e. green field) |

|  | [pic]Financial restructuring of existing company |

|  | [pic]Expansion of existing company |

|  | [pic]Privatization |

|  |

|1.10 |By what date do you |[pic]  [pic] [pic] |

| |expect to make your | |

| |investment in the | |

| |host country? | |

|  |

|1.11 |Factors that may influence/delay expected investment date |

|  | |

|  |

|1.12 |Size of Investment: |

| |  |

|a. |For non-financial sector projects only: Size of SME into which investment is being made (must meet two out of three criteria relating to |

| |number of employees, asset size and annual sales): |

| | |

| |SIZE |

| |CRITERIA |

| | |

| |Micro |

| |[pic]Employees ................
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