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Securities Based Loan application form

 Dollar Amount You Are Seeking __________________________

Quantity of Stock Available  ________________________________

Stock Symbol ______________

Name of Public Company _____________

The Stock Is Free Trading [ ]

 Restricted [ ]

If Restricted, Are Shares Aged 12 Months or More?

Yes ______

No _____

Form of Stock Certificate [ ]

Electronic (Brokerage Account) [ ]

Name of Brokerage Firm Held At _________________________

Your Shareholder Status Officer of the Company (Affiliate) [ ]

Director or Board Member (Affiliate) [ ]

Shareholder With 10% or More of Stock (Affiliate) [ ]

Shareholder With Less Than 10% of Stock (Non-Affiliate) [ ]

Full Name of Borrower ________________________________

Email Address ________________________________________

Day Time Phone _________________________________

Mobile Phone ____________________________________

FAX _______________________________

Skype _____________________________

Referring Agent ________________________________

Referring Agent Fee (      ) _________________________

Comments___________________________________ 
  
____________________________________________
Dan R.Cassel
Securities loans and real property loans
Ca DRE # 01146347 NMLS# 347918
Direct number 858-204-6209   Return FAX 858-605-4225
Dan R. Cassel, is a California State and Federal certified MLO. He is not a Certified Financial Advisor, Securities Broker.