ࡱ>  1;,-./0>}i#`Lbjbjmm :xt*******>jjj8l> 4AL(qKsKsKsKAKhg$hp@ *ccc@**M&c&**qKcqKFo!**' 8OjD%T},s<c%Lcc''nc*(`V @@MXcccc>>sy$>>y>>>******  Application Insurance of Capital investment Before answering these questions, please consult the explanatory notes at the end of this form.  Other application forms can be downloaded from:  HYPERLINK "http://www.atradius.com/nl/en/dutchstatebusiness/documenten/aanvraagformulieren/index.jsp" http://www.atradius.com/nl/en/dutchstatebusiness/documenten/aanvraagformulieren/index.jsp (Use the correct application form for your transaction)  The processing of your application by Atradius: 1. After we have received your application, we will send you an acknowledgement of receipt. 2. As soon as we have the necessary information at our disposal, we will be able to process your application. 3 If the investment amount is EUR 10 million or more, we request you to complete questions 7e up to and including 7q and to provide required annexes. In some cases, we will also request you to complete these questions if the investment amount is below EUR 10 million. 4. While your application is being processed, we will keep you informed regularly about the current progress. 5. You will be required to pay the following costs in connection with the processing of your application (barring possible changes)Processing costs for your investment application :0.1% of the investment amount. (min. 450 and max. 4,500)( In case your application is rejected we will reimburse you 50% of the processing costs)Costs for the first renewal of the promise of cover :25% of the processing costs. (min. 150 and max. 450)   1. The Applicant a. Name of the applicant, as listed in the Trade Register: FORMTEXT       Business address (including post code): FORMTEXT       Address for correspondence (including P.O. Box and post code): FORMTEXT       Telephone:  FORMTEXT       Fax:  FORMTEXT       Contact person Mr/ Ms.: FORMTEXT       Telephone / extension no. of contact person:  FORMTEXT       Position of contact person:  FORMTEXT       b. Group of which the applicant is part: FORMTEXT       c. Legal form: FORMTEXT       If the applicant is not a legal person, the name, address and nationality of the proprietors: FORMTEXT       If the applicant is a legal person, the percentage of the share capital that is in Dutch ownership.  FORMTEXT      % d. Other documents that give evidence of the Dutch nature of the applicant: FORMTEXT       (It is advisable to send with this form any information which you have about the business referred to below, e.g. annual reports, or other information about its financial circumstances that you have in your possession) 2. The Beneficiary Name of the business in which the investment is to be made: FORMTEXT       Full address and country: FORMTEXT      Date of establishment and objects: FORMTEXT        Year:  FORMTEXT       Object:  FORMTEXT       How is the business managed? (See explanatory note 2d) FORMTEXT       e. Who are the other investors and what are their respective percentages of the capital investment?  Name : Country:Percentage FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      f. Do you have existing capital investments in this business? FORMCHECKBOX  Yes  FORMCHECKBOX  No  What has been your experience of these capital investments? FORMTEXT       3. The capital investmenta. Nature of the capital investment: (Money, goods or services)  FORMTEXT      b. Form of the capital investment: (See explanatory note 3b) FORMTEXT      c. Purpose of the capital investment: (See explanatory note 3c) FORMTEXT      d If the capital investment is in the form of goods, are they being manufactured by you? (if not, please explain) FORMCHECKBOX  Yes  FORMCHECKBOX  Noe. What is the importance of the proposed capital investment to the country in which the investment is to be made? FORMTEXT       4. Amount of the capital investmenta. What is the amount of the proposed capital investment in :   FORMTEXT       Foreign currency : FORMTEXT      b. Will titles and/or security be received in return for the capital investment? (See explanatory note 4b) FORMCHECKBOX  Yes  FORMCHECKBOX  No Nominal value (if so, please state the nominal value)  FORMTEXT      c. Does the investment agreement provide for repayments and/or redemptions? (If so, please state the maximum percentages or amounts and the interest rate) FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMTEXT      d. What are the expected proceeds? (See explanatory note 4d) FORMTEXT      e. How and when will the repayments and/or redemptions or the proceeds be determined or paid? FORMTEXT       5. Investment dates a. Start date of the investment :  FORMTEXT       b. Date investment completed :  FORMTEXT      c. Duration of the investment :Maximum :  FORMTEXT      Or until :  FORMTEXT       6. Country of investmenta. Conditions of repayments and/or redemptions: (See explanatory note 6a) FORMTEXT      b. Time taken to process transfer application: (See explanatory note 6b) FORMTEXT      c. Has the government of the country of investment approved the investment? FORMCHECKBOX Yes  FORMCHECKBOX  No  (If so, which document evidences this approval? Please attach a copy) (If not, why not?) FORMTEXT       FORMTEXT       FORMTEXT      d. Description of the contracts: (See explanatory note 6d) FORMTEXT       FORMTEXT       FORMTEXT      e. Does special legislation apply? (See explanatory note 6e) (If so, please attach a copy) FORMCHECKBOX  Yes  FORMCHECKBOX  NoDo provisions and/or government decisions apply? (If so, please attach a copy. See explanatory note 6f) FORMCHECKBOX  Yes  FORMCHECKBOX  No 7. Corporate Social Responsibility I. Fundamental labour standards (see explanatory note 7a)a. Does the capital investment involve, during the period of the capital investment:  child labour?  FORMCHECKBOX  Yes  FORMCHECKBOX  No forced labour?  FORMCHECKBOX  Yes  FORMCHECKBOX  No restrictions on the right of association and collective bargaining for employees? FORMCHECKBOX  Yes  FORMCHECKBOX  No (If one of these questions has been answered  Yes , please explain) FORMTEXT        II. Bribery(see explanatory note 7b tot d) b. Are you aware that in connection with the capital investment to which this application relates any payment or donation has or will be given or offered; - any pledge has or will be made; - any service has or will be performed or offered; - any benefit of whatever nature (including intangible benefits and benefits in kind) has or will be awarded, pledged or offered, by you or by another person to persons who are in the public service of a foreign state or public international body, whether or not this is dependent on the fulfilment of a further condition or conditions, which payment, donation, pledge, service or benefit could be interpreted in such a way that bribery or attempted bribery has taken place or will take place, or at least that an attempt has or will be made in an improper manner to obtain a competitive advantage, a better negotiating position, more favourable contract terms, or any other benefit?   FORMCHECKBOX  Yes  FORMCHECKBOX  No c. Are you listed on one of the publicly available debarment lists of the following international financial institutions: World Bank Group, African Development Bank, Asian Development Bank, European Bank for Reconstruction and Development and the Inter American Development Bank? (See explanatory notes) FORMCHECKBOX  Yes  FORMCHECKBOX  No d. Are you, or anyone acting on your behalf in connection with the transaction, currently under charge in a national court or, within a five-year period preceding the application, have you been convicted in a national court or been subject to equivalent administrative measures for violation of laws against bribery of foreign public officials of any country? FORMCHECKBOX  Yes  FORMCHECKBOX  No III. Environmental and social aspectsBefore answering these questions, please read point 3 on the cover page to determine if you need to complete this section. In case the contract price is less than EUR 10 million, but it concerns a sensitive sector, or the transaction, or project of which the transaction is a part of, is located in a sensitive area we will request you to complete these questions. (See explanatory notes for question 7e to q). If this is not the case, please continue with question 8. e. Correct address, place and description of the investment location: (Please provide us with a detailed map of the location)f. As or for what is the investment location currently used ?  Urban  FORMCHECKBOX   Industrial  FORMCHECKBOX  Agricultural  FORMCHECKBOX  Greenfield  FORMCHECKBOX  Other, please specify:  FORMTEXT        FORMCHECKBOX g. In which sector will the investment be made? Mining, oil and gas exploration  FORMCHECKBOX  Iron and steel  FORMCHECKBOX  Petro-chemicals  FORMCHECKBOX  Energy production and distribution  FORMCHECKBOX  Land reclamation and dredging  FORMCHECKBOX  Dams and hydro-electric power  FORMCHECKBOX  Other infrastructure and civil engineering  FORMCHECKBOX   Large-scale agri- or horticulture  FORMCHECKBOX   Other sector, please provide details  FORMTEXT        FORMCHECKBOX   h. What type of sensitive location could face an adverse environmental impact from the investment? (Please mark all relevant boxes)Investment LocationEffect areaSemi-arid or desert margins  FORMCHECKBOX   FORMCHECKBOX Tropical or sub-tropical rainforest  FORMCHECKBOX   FORMCHECKBOX  River deltas, coastal areas, mangroves or coral reefs  FORMCHECKBOX   FORMCHECKBOX National parks  FORMCHECKBOX   FORMCHECKBOX World Heritage List/World Biosphere Reserve areas  FORMCHECKBOX   FORMCHECKBOX Rare/threatened species habitats  FORMCHECKBOX   FORMCHECKBOX Areas of very high population density  FORMCHECKBOX   FORMCHECKBOX Areas of archaeological significance  FORMCHECKBOX   FORMCHECKBOX Areas with indigenous peoples  FORMCHECKBOX   FORMCHECKBOX Other sensitive location, please provide details  FORMTEXT        FORMCHECKBOX   FORMCHECKBOX  Environmental and Social Impact Assessmenti. Does the investment have an analysis of its environmental and social effects and associated preventive measures, e.g. an Environmental Impact Assessment, an Environmental Impact Statement or Social Impact Assessment? (See explanatory notes)  FORMCHECKBOX  Yes  FORMCHECKBOX  No (If yes, please provide a document written in English or Dutch)j. If yes, what is the status of the impact assessment report:- In progress  FORMCHECKBOX - Draft version available  FORMCHECKBOX - Approved by  FORMTEXT      (name organisation)  FORMTEXT       FORMTEXT        FORMTEXT      (date) FORMCHECKBOX  k. Has a management plan been developed (ESMP) for the investment, covering measures to mitigate potential negative environmental and social impacts? (See explanatory note)  FORMCHECKBOX  Yes  FORMCHECKBOX  No (If yes, please provide a document written in English or Dutch)l. Will there be resettlement as a consequence of the investment?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMTEXT      m. Does your investment apply environmental standards and management systems? If yes, please specify.  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMTEXT      n. What standards do the techniques used meet? Please give details. (e.g. Best Available Technique (BAT)).  FORMTEXT      Environmental legislation and standardso. Which local and international environmental legislation and/ or standards are applicable for the investment? Please specify and add an annex if needed.  FORMTEXT      p. Who is the competent authority that verifies whether the investment complies with the applicable legislation and/or standards? Please specify and add an annex if needed. FORMTEXT      q. What kind of environmental permits are or will be granted? Please provide details permit name, competent authority and date the permit was or will be granted. If needed you may provide this information in an annex. 8. Cover requiredWould you like to partially or fully transfer the portion not covered by Atradius (your own risk)? (If yes, which portion and to whom?) FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMTEXT      Which cover do you require? (you can tick one or more boxes)  Expropriation  FORMCHECKBOX   War  FORMCHECKBOX   Transfer risk  FORMCHECKBOX   Breach of contract by a public party  FORMCHECKBOX   9. Other information The application concerns: A promise of cover (in case the investment has not yet commenced)  FORMCHECKBOX  An insurance policy (in case the investment has commenced)  FORMCHECKBOX  A pro-forma application to support an application of the financing bank  FORMCHECKBOX   If we have already issued a promise of cover for this investment, what is the reference number of this promise of cover?.  FORMTEXT       Will a bank offer financing to the beneficiary in relation to this investment? Is it the intention that this financing will be insured by Atradius by way of a Financing Policy? (If yes, then the bank must submit an application with us as soon as possible) If information on a possible financing becomes known to you only at a later stage, then we request you to inform us without delay. (See also under Signature, third tiret)  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Yes  FORMCHECKBOX  No For this investment, has an application been made, or will be made, to the Dutch authorities for a grant, aid financing or any other subsidy, through which (part of) the investment will be paid? (If yes, for which part of the investment and what is the reference number?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Amount:  FORMTEXT       Reference Number:  FORMTEXT        e. Are there any facts or circumstances about which information has not been requested specifically above, but that may be relevant to an assessment of the application by Atradius? (If yes, please explain. See explanatory notes)  FORMCHECKBOX  Yes  FORMCHECKBOX  No  10. Signature The undersigned declares: - that the questions in this form have been answered correctly and completely and that no circumstances of importance to Atradius have been concealed; - that the information provided in this application form gives a true and complete picture of the non-payment risks involved in this transaction, as known to him at the time of submission of this application; - that he will notify Atradius without delay in writing of any fact or circumstances which become known to him after the submission of this application; - that, during a period of 60 days from the date of receipt by Atradius of this application, he undertakes to accept the promise of cover or, as the case may be, the policy; - that he has taken note of the OECD Guidelines for Multinational Enterprises and will endeavour to apply these in his business to the best of his ability; that in connection with the capital investment to which this application relates he will at all times refrain from bribery as referred to in question 7 of the application form and the explanatory note thereto and from inciting or being an accessory to such bribery; the information provided in this form is a full and accurate picture of the environmental and social impact associated with the capital investment, as known to him/her at the time the application was submitted; he will immediately notify Atradius in writing of facts and/or circumstances which become known to him/her after submission of this form and which could be significant for the assessment of the environmental and social impact.Incomplete or inaccurate information in this form may result in a delay of processing the application. If, before issuing the policy, it appears that you were or should have been aware of not reported facts or circumstances which were relevant for the assessment of the application, this may result in a laps of entitlement to indemnity or reclamation of compensation paid.Place/ Town : FORMTEXT      Date : FORMTEXT      Name : FORMTEXT      Signature : FORMTEXT       FORMTEXT       The officer who signs this application should be competent to commit the applicant to at least amounts of the same order of magnitude as the amount of the investment to be insured. If your investment is classified as an A-project, the project as well as the environmental and social information or a summary of this will be made public at least 30 calendar days before the issuing of the policy.If your application results in a policy being issued, Atradius will publish certain information about your investment on its website one month after the date of issue of the policy. (See explanatory note) Explanatory notes to the questions on the application form entitled "Insurance of Capital Investment" Question 2d:Supervisory Board, Management Board, Directors (specifying any other positions held by these directors).Question 3c:Participation in share capital, agreement granting rights and/or services, long-term loan.Question 3d:For example, the establishment or expansion of a factory, foundation or the improvement of an enterprise, stating where the goods, rights or services delivered will be located or used. Question 3g:Semi-desert areas or deserts, tropical or subtropical rain forest, river deltas, coastal areas, mangroves or coral reefs, national parks, areas on the World Heritage List (www.unesco.org/whc/heritage.htm) / List of World Biosphere Reserves (www.unesco.org/mab/brlist.htm) habitats of rare / endangered species, areas with a very high population density, areas of archaeological value or other areas. Question 4a:Analysed by the nature of the capital investment (see 3a), including a description of the goods, services, etc. to be delivered. Question 4b:For example, shares, bonds, etc. Question 4d:For example, dividends, interest, salaries, wages or royalties. Question 6a:Which conditions apply regarding the repayment or redemption of the capital investment and payment of the proceeds in the country of investment? Question 6b:How much time do you estimate the authorities in the country of investment will need in order to process the application for the conversion of local currency into euros for the repayment or redemption of the capital investment and payment of the proceeds? Question 6d:Brief description of the contracts and other agreements between the government of the country of investment and the applicant, and/or with the business in which the investment is being made. Question 6e:For example, laws regarding new industrial establishments. Question 6f.:Are there any administrative provisions and/or government decisions that apply to the capital investment or to the business in which the capital investment is to be made? Question 7a:Atradius will under no circumstances become involved in insuring capital investments which are associated with breaches of fundamental labour standards laid down in Treaties Nos. 29, 87, 98, 100, 105, 111, 138 and 182 of the General Conference of the International Labour Organisation (ILO), unless compliance is not possible as a result of legislation in the emerging market concerned. Well-founded suspicions that these fundamental labour standards are being or will be breached will also be regarded as grounds for rejecting the application. If there is uncertainty regarding the question of the extent to which the activities of the local business will breach one of these standards this must be explained in further detail by the applicant. A more detailed description of the four fundamental labour standards laid down in these treaties is available from Atradius. This is also available on the web site of the Ministry for Economic Affairs: http://www.oesorichtlijnen.nl Question 7bAtradius will under no circumstances become involved in investments in which bribery has taken place, bribery being interpreted for this purpose in the broadest terms. The question includes a list of terms of bribery that is not exhaustive. Even if the bribery concerned is a form of bribery that is not listed explicitly, or if you have reasons to suspect that there may be question of such a form of bribery, you must declare this bribery in your answer. 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