Form OPIC-241 EDN Loan/Insurance Originator Application Questionnaire

ENTERPRISE DEVELOPMENT NETWORK (EDN)

LOAN/INSURANCE ORIGINATOR APPLICATION QUESTIONNAIRE

PART I—Business Information

Thank you for your interest in OPIC’s EDN Originator function. OPIC is inviting qualified organizations to submit applications for participation in EDN. Please provide all of the information requested in this Questionnaire. Your responses are for OPIC’s internal information only and will not be shared outside of OPIC other than with the EDN Program Manager. Feel free to add additional information that you think would be relevant.

1. SME Profile & Strategy

1. Organization Overview

1. Using the table below, lease provide details of your organization’s project origination activities:

Date of Closing	Company Size	Project Size	Funding Type (i.e. debt, equity, insurance)	Size of Funding	Industry Sector	Country	Other Categorizations
     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     

2. If your organization participates in SBA, Export-Import Bank or other relevant federal business financing, credit insurance or feasibility funding programs, what is the level of participation (provide basic business volume indicator)?

     

3. Please note whether your organization specializes in any particular industry or sector (e.g. telecom, financial services, tourism, power)

     

3. Please note whether your organization specializes in any particular country or global region.

     

3. What experience has your organization had with OPIC, if any?

     

2. Project Origination

1. Describe briefly the process used by your company for project origination.

     

2. Define the type of project that your organization targets – business type, management profile, company, stage of development, etc.

     

3. What is your current SME marketing plan & how is it executed?

     

4. Does your organization have formal relationships with private financial service providers through which you currently originate applications for their approval? Please describe the kinds of institutions you work with.

     

3. Technology

1. Describe your organization’s use of technology throughout the SME project origination process. Do you offer on-line application processing? Do you use the internet for marketing and prospect identification? What computer-based applications/versions do you use (e.g., Microsoft Word, Excel, ACT)?

     

2. Team

1. Provide the names and the length of time with the firm for each key member of your organization’s prospective EDN Origination team.

     

2. Provide biographical summaries for each of the key members of your prospective EDN Origination team, including relevant experience. 

     

3. Provide a current organizational chart (or charts) for the area(s) supporting EDN.

     

PART II—Background Information

Definitions: As used in this Part II, the following terms, when capitalized, have the meanings ascribed to them below:

“Affiliate” means, with respect to any Person, either:

1. any other Person that is directly or indirectly controlled by, under common control with or controlling such Person; or,

2. any executive, officer or director of such Person[, except that, with respect to a Reporting Company, only executives, officers and directors covered by or subject to SEC reporting requirements applicable to such Reporting Company].

“Person” includes, without limitation, individuals, corporations, joint stock companies, partnership, associations, trusts, banks, trust companies, business trusts or other organizations, whether or not a legal entity, as applicable.

“Originator” means a Person who is applying to become an Originator through the OPIC Enterprise Development Network.

“Reporting Company” means either a Person whose securities are registered pursuant to Section 15 USC 78(m) of the Securities Act of 1933, as amended, or is required to file reports with the SEC pursuant to the SEC Acts.

“SEC” means the U.S. Securities & Exchange Commission (or successor thereof).

“SEC Acts” means, individually or collectively, as the context requires, the Securities Act of 1933, the Securities Exchange Act of 1934, or the Investment Company Act of 1940, each as amended from time to time.

The original of this form, as submitted to OPIC, must be signed in blue ink. Please identify the Originator at the top of each sheet, and type or print clearly. All requested information must be provided completely and accurately in order to comply with requirements under the Foreign Assistance Act of 1961, Title IV, as amended. Please attach additional pages if additional space is required. If the answer to a question is “not applicable” or “none”, please so indicate by stating “N/A” or “NONE”, as the case may be, or as otherwise instructed for a specific question. When using an attachment to answer any of the questions in this form, please write: “See Attachment # __” in the appropriate answer block and indicate on the attachment the number of the question it is intended to answer.

Please provide the following information:

1. Full and Complete Name of the Originator (see definition above) submitting this report.

a. If an individual, full name (including first, middle, and last names). If no middle name, please state “NMN”:

     

For this individual, please provide the information requested in Questions

1(a)(i) through 1(a)(vii), below.

i. Nicknames or aliases (if applicable):      

ii Date of birth:      

iii. Place of birth:      

4. Maiden name and married name(s) (to the extent

applicable):      

4. Please list all locations where this individual resides and has

resided over the course of the ten years immediately preceding the date hereof (for locations in the United States, include all states, territories, possessions, and the District of Columbia), beginning with place of current residence:      

4. If doing business as a sole proprietorship, please provide trade (DBA) name, jurisdiction of registration (if any), and registration number (if any):      

4. Please provide country of citizenship, passport number (or similar identification number if passport is not available), and driver’s license number (including jurisdiction of issuance):      

b. If a corporation or company, legal name as it appears on the certificate of incorporation or similar document, and place of incorporation:      

If a Reporting Company, please specify the exchange(s), if any, on which its securities are listed (or, alternatively, by what manner its securities are publicly traded), as well as the date and nature of its latest securities law filing:      

c. If a partnership, name of partnership as it appears on the certificate of formation or similar document, and place of formation:      

For this partnership, please provide the information requested in Questions 1(c)(i) through 1(c)(ii), below.

i. If the general partner is an individual, please provide country of citizenship and passport number (or similar identification number if passport is not available):      

ii. If a Reporting Company, please specify the exchange(s) on which its securities are listed, as well as the date and nature of its latest securities law filing:      

d. If a trust, business association or other entity, name of trust, business association or such entity as it appears on the agreement establishing such trust, business association or other entity, and place of formation or establishment:      

For this trust, business association or other entity, please provide the information requested in Questions 1(D)(i) through 1(D)(iv), below.

i Is the trustee an Affiliate of the Originator (check the applicable box):

Yes No Not Applicable (i.e., not a trust)

ii If the answer to Question 1(D)(i) is “No”, please provide the name of the trustee:      

iii Please provide country of citizenship and passport number for the trustee (or similar identification number if passport is not available):      

iv If a Reporting Company, please specify the exchange(s) on which its securities are listed, as well as the date and nature of its latest securities law filing:      

2. Originator Contact Information

Address:       City:       State/Province:      

Country:       Zip/Postal Code:      

3. If a corporation, company, partnership, trust, business association or similar entity

Federal Taxpayer Identification Number:      

4. If an individual, Social Security Number (only if Originator is an individual):

     

5. Name of authorized representative(s) OPIC should contact for information:

Title:      

Address:      

City:       State:       Zip Code:      

Telephone:       Fax:       E-Mail:      

6. Please list below the names (including, if an individual, full legal name including middle name, or “NMN” if no middle name) and principal address of each Affiliate of the Originator, along with country of citizenship or formation. Please indicate, for each Affiliate, whether such Affiliate is a Reporting Company.

For Reporting Companies, check the box at the end of this sentence and provide responsive information from applicable securities filing(s) as an exhibit for purposes of this disclosure.

Name of Affiliate (if an individual, include full legal name with middle name or “NMN” if no middle name)	Principal Address of Affiliate	Country of Citizenship or Formation of Affiliate	Reporting Company? (yes or no)
     	     	     	Yes No
     	     	     	Yes No
     	     	     	Yes No
     	     	     	Yes No
     	     	     	Yes No

7. Is the Originator or any Affiliate of it currently delinquent on any payment obligation, including taxes as well as other obligations, with respect to any amount owed to the U.S. Government? Yes No

If “Yes”, please explain      

8. Is the Originator or any Affiliate of either of it currently: (1) debarred, suspended or declared ineligible from participating in any Federal program; (2) formally proposed for suspension or debarment, with a final determination still pending; or (3) voluntarily excluded from participation in a Federal transaction? Yes No

If “Yes”, please explain:      

9. In responding to the questions below, the term “owners” means:

1. if the Originator is a sole proprietorship, the proprietor;

2. if the Originator is a partnership, each partner holding a partnership interest in excess of twenty percent (20%); or

3. if the Originator is a corporation or company, each beneficial holder of five percent (5%) or more of the voting stock.

The fact that an owner, officer or director of the Originator has an arrest or conviction record will not necessarily disqualify the Originator, but a misrepresentation could cause the application to be turned down.

a. Is the Originator, any Affiliate thereof, or any of their respective owners, officers, or directors presently under indictment or on parole or probation? Yes No

If “Yes”, please explain:      

b. Has the Originator, any Affiliate thereof, or any of their respective owners, officers, or directors ever been charged with or arrested for any criminal offense other than a minor motor vehicle violation? Yes No

If “Yes”, please explain:      

c. Has the Originator, any Affiliate thereof, or any of their respective owners, officers, or directors ever been convicted, placed on pretrial diversion, or placed on any form of probation, including adjudication withheld pending probation, for any criminal offense other than a minor motor vehicle violation? If “Yes”, please provide below, for each such proceeding, date(s), case number(s), parties, court(s), nature of the action, and final (i.e., no longer subject to appeal) disposition. Yes No

If “Yes”, please explain:     

For Reporting Companies, check the box at the end of this sentence and

provide responsive information from applicable securities filing(s) as an

exhibit for purposes of this disclosure.

Date(s)	Case Number(s)	Parties	Court(s)	Nature of Action	Final Disposition
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     

d. Has the Originator, its Affiliates, or their respective owners, officers, or directors ever been found by a court of competent jurisdiction in a civil action or by the U.S. Securities and Exchange Commission or similar U.S. or state agency to have violated any U.S. Federal or U.S. state securities law? Yes No

If “Yes”, explain:      

For Reporting Companies, check the box at the end of this sentence and

provide responsive information from applicable securities filing(s) as an

exhibit for purposes of this disclosure.

e. Has the Originator, its Affiliates, or their respective owners, officers, or directors ever been found by a court of competent jurisdiction in a civil action or by any state insurance regulatory authority to have violated any state law governing the regulation of the insurance industry? Yes No

If “Yes”, explain:      

f. Is the Originator or its Affiliates, or their respective owners, officers, or directors a party to any consent judgment or agreement with the U.S. Securities and Exchange Commission that restrains or restricts its activities? Yes No

If “Yes”, explain:      

For Reporting Companies, check the box at the end of this sentence and provide responsive information from applicable securities filing(s) as an exhibit for purposes of this disclosure.

g. Has the Originator or its Affiliates, or its respective owners, officers, or directors ever been involved as a plaintiff or defendant in any material litigation that has not been satisfied, settled or compromised over the course of the ten year immediately preceding the date hereof?

Yes No

If “Yes”, please provide below, for each such litigation matter, date(s), case number(s), parties, court(s), nature of the action, and final (i.e., no longer subject to appeal) disposition.

For Reporting Companies, check the box at the end of this sentence and provide responsive information from applicable securities filing(s) as an exhibit for purposes of this disclosure.

Date	Case Number(s)	Parties	Court(s)	Nature of the Action	Final Disposition
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     

h. With respect to any of the Originator, its Affiliates, or their respective owners, officers and directors, are there any pending or threatened administrative investigation or proceedings for which the imposition of a lien is or may be sought, or any administrative lien(s) that has been ordered or imposed.

Yes No

If “Yes”, please provide below for each matter, the amount of the lien or judgment, name(s) of judgment creditor(s) or lienholder(s), case number(s), court(s) or name(s) of agency (-ies), nature of the case or investigation, and final (i.e., no longer subject to appeal) disposition.

For Reporting Companies, check the box at the end of this sentence and provide disposition information from applicable securities filing(s) as an exhibit for purposes of this disclosure.

Amount (in US$ or equivalent)	Name(s) of Judgment Creditor(s) or Lienholder(s)	Case Number(s)	Court(s) or Name(s) of Agency(ies)	Nature of the Case or Investigation	Final Disposition
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     

10. Has the Originator, its Affiliates, or any of their respective officers, directors or executives

been the subject of an investigation under the Foreign Corrupt Practices Act of 1977 (as amended) or other applicable law concerning corrupt business practices?

Yes No

If “Yes”, please explain:      

For Reporting Companies, check the box at the end of this sentence and provide responsive information from applicable securities filing(s) as an exhibit for purposes of this disclosure.

11. Has the Originator, the Project Company, their respective Affiliates, or their officers, directors, employees, or agents (in such capacity) been convicted of, or been party to a final adverse determination of, an offense under the Foreign Corrupt Practices Act of 1977 (as amended) or any other applicable law concerning corrupt business practices?

Yes No

If “Yes”, please explain:      

For Reporting Companies, check the box at the end of this sentence and provide responsive information from applicable securities filing(s) as an exhibit for purposes of this disclosure.

12. Notification of investigation:

As part of the application process for the Enterprise Development Network, OPIC routinely undertakes investigations of applicants for participation in the network. OPIC considers such investigations to be an essential element in evaluating the qualifications of the Originator and its Affiliates (as such term is defined in the instructions). These investigations may involve the use of private consumer credit reporting firms, court clerks and government agencies. The investigations may focus on, but are not necessarily limited to, the business reputation, character, overdue and unpaid tax obligations, criminal record, and general reputation of the Originators and their Affiliates, and their respective principal officers and directors. The nature of the investigations will be at the discretion of OPIC, and, by signing below, the Originator consents to such investigations by OPIC and its agents. Under the Fair Credit Reporting Act, 15 U.S.C. §1681, the undersigned may be entitled to additional information regarding the nature and scope of any investigation of which it is the subject if requested by it in writing. OPIC is required to verify that each Originator (who has a Taxpayer Identification Number or a Social Security Number) is not delinquent on any Federal tax obligations. Signature of this form constitutes the undersigned’s consent to such investigations, checks and verification.

The undersigned, as either the Originator (in the case of an individual) or as the duly authorized representative of the Originator (in the case of Persons other than an individual), including their respective Affiliates as the case may be, certifies on behalf of the Originator and its Affiliates that the information and certifications provided in response to the questions herein, under penalty of law (pursuant to 22 USC Section 2197(n)), are true and correct to the best of such Person’s knowledge after due inquiry, and that such Person has not misrepresented or omitted any material facts relevant to said representations. If after the date hereof the Originator comes into possession of any information material or relevant to said representation, the Originator agrees not to withhold it, and the undersigned agrees to communicate such knowledge to OPIC immediately by facsimile or by letter, as appropriate.

Name of Originator Applicant (on behalf of itself and its Affiliates)

     

Signature of Authorized Person (in blue ink) Date

Title of Authorized Person (Please Print):      

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