U. Proposed method of repayment of loan. (Sute sources of funds and proposed schedule of repayment on separate sheet.) 



12. Are there now, or have there been in the past 5 yeais, any Judgements or compromise settlements obtained against you or your corpo- 

 ration relating to your business? . If so, sUte nature and present status on separate sheet. 



13. Have you been involved in any bankruptcy proceedings at any time, or made an assignment for benefit or creditore, etc.? Cive full 

 details and other pertinent information relating to these matters. (Use separate sheet.) 



14. NAMES OF ATTORNTt'S, ACCOUKTANTS AND OTHER PARTIES. The names of all attorneys, accountants, appraises, agents and 

 all other parties (whether individuals, partnerehips, associations or corporaUons) engaged by or on behalf of the applicant (whether on 

 a salary, retainer or fee basis and regardless of the amount of compensation) for the purpose of rendering professional or other services 

 of any nature vviiatever to applicant, in connection with the preparation or presentation of this application or with any loan to appli- 

 cant which the Department of the Interior may make, or in vrfiich the Department of the Interior may participate, as a result of this 

 application, or such loan or participation; and all fees or other charges or compensation paid or to be paid tiierefor or for any purpose 

 in connection with this application whether in money or other property of any kind whatever; b>- or for the account of the applicant, 

 together with a description of such services rendered, are as follows! 



NAME AND ADDRESS 



DESCRIPTION OF SERVICES 



RENDERED AND TO BE 

 RENDERED 



TOTAL COMPENSA- 

 TION AGREED TO 

 BE PAID* 



COMPENSATION 

 ALREADY PAID 



APPLICANT SHOULD IMMEDIATELY NOTIFY THE DEPARTMENT OF THE INTERIOR OF ANY CHANGE IN OR 



ADDITION TO THE INFORMATION SET FORTH ABOVE 

 * Subject to the Department of the Interior approval. 



IS. NAMES OF ANY DEPARTMENT OF THE INTERIOR OR SRA* EMPLOYEES who have any relationdiip or direct or indirect interest 

 whatsoever in applicant (such interest to include any direct or indirect financial interest in any other business entity or enterprise 

 which is. in any way, connected with applicant): 



NAME AND ADDRESS 



INTEREST IN APPUCANT 



AGREEMENT ON NONEMPLOYMENT OF DEPARTMENT OF THE INTERIOR OR SBA* PERSONNEL. In considejation of the making by 

 the Department of the Interior to applicant of all or any part of the loan applied for in this application, applicant hereby agrees with 

 the Department of the Interior that applicant will not, for a period of two years after disbursement by the Department of the Interior to 

 applicant of said loan, or any part thereof, employ or tender any office or employment to or retain for professional services any person 

 who, on the date of such disbursement, or within one year prior to said date, (a) shall have served as an officer, attorney, agent of the 

 Department of the Interior or SBA and (b) as such, shall have occupied a position or engaged in activities which the Department of the 

 Interior or SBA shall have determined, or mav determine, involve discretion with respect to the granting of assistance under the Fish 

 and Wjldliic Act of 1956, or said act as it may be amended from time to time. _^ 



17. CERTIFICATION: I hereby certify that: 



(A) The applicant has not paid or Incuned any obligation to pay, directly or indirectly, any fee or other compensation for obtaining 



the loan hereby applied for, and has not paid or will not make any payment for services in connection with this applical-on, 

 without the consent of the Department of the Interior. 



(B) Ail information contained above and in exhibits attached hereto axe true and complete to the best knowledge and belief of the 



applicant and are submitted for the purpose of inducing the Department of the Interior to grant a loan, or to participate in a 

 loan by a bank or other lending institution, to applicant. Whether or not the loan herem applied for is approved, applicant 

 agrees to pay or reimburse the Department of the Interior for the cost of any surveys, title or mortgage examination, appraisals, 

 etc. , performed by non-Department of the Interior personnel with consent of applicant . 



(Name of Applicant) 



If A Corporation 



(SEAL) 



By. 



(Title) 



Whoever makes any statement knowing it be false, or whoever willfully overvalues any security, for the purpose of obtaining for 

 himself or for any applicant any loan, or extension thereof by renewal, deferment of action, or otherwise, or me acceptance, release, or 

 substitution of security therefor, or for the purpose of influencing in any way the action of the Department of the Interior, or for the 

 purpose of obtaining money, property, or anything of value, under the Fish and Wildlife Act of 1956 shall be p uni s h ed as prescribed by 

 law. 



* Small Business Administration. 



10 



