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INFORMATION SHEET AND APPLICATION FORM

Name of Institution
Postal Address
Tel. No.
Fax. No.
E-mail Address
Website URL
Brief History of Institution
Name of Principal Officers and Titles
Name and Title of Members of your Board of Directors
Number of Officers
;
Staff
;
Total
Total Assets as of
Date
(in Equiv. US Dollars)
Total paid-Up Capital as of
Date
(in Equiv. US Dollars)
Capital Sharing (%)
Principal Areas of Financing Undertaken. (Agricultural, Commercial, Industrial, Etc.)
Approximate Percentage of Loan Portfolio
Area
% of Portfolio
Areas where Association can be best of assistance to you: (Check as appropriate)
 Staff and Professional Development Information Exchange on Aspects of Development Finance Others, please specify
EVIDENCE OF COVENANT
In fulfillment of our Institution’s membership in the Association and as provided under Article 6.1 of the Association’s Constitution, we hereby agree to be bound by the Constitution, the rules and the By-laws thereof and the interpretation of the Constitution, rules and By-laws made from time to time.
I accept this term