CIS Form

LOAN APPLICATION FORM

 Loan Application Form

In accordance with Articles 2 through 5 of the Due Diligence Convention and the Federal Banking Commission Circular of
December 1998, and under the US Patriot Act of 2002, as amended in February 2003 concerning the prevention of money
laundering and 305 of the Swiss Criminal Code, the following information may be supplied to banks and/or other financial
institutions for purposes of verification of identity and activities of the Client described below, and the nature and origin of the
funds which are to be utilized.

The foregoing is subject to agreement by all parties to whom this information is provided that they are obligated to respect the
privacy rights of the Client and all individuals described herein, as well as the generally accepted professional standards relating
to the maintenance of confidential information, and to take all appropriate precautions to protect the confidentiality of the
information contained herein, This legal obligation shall remain in full force indefinitely without restriction.

IMPORTANT: Please select which one of the following: I want to: [ ] Apply for a Loan ONLY [ ✓ ] Seek for Equity [ ]
Combination of Debt and Equity [ ] Other solutions; Please describe! ...................................................................

Personal Information
Please fill this form in ENGLISH and in BLOCK LETTERS your personal details.

A. IDENTITY DETAILS

1. Name of the Applicant: Moh Feisal Rizky Kasmin ....................................................................................

2. Other Name(s): if any: ...............................................................................................................................................

3. a. Gender: Male b. Marital status: Married c. Date of birth: 27/09/1990 (dd/mm/yyyy)

4. a. Nationality: Indonesia. b. Status: Non-Resident

5. a. SSN: ................?.......................... b. National ID No: 72710127099000003

6. Specify the proof of Identity submitted: ....................................................................................................................

B. ADDRESS DETAILS

1. Residence Address: Jln. Dr. Samratulangi No. 87

City/town: Kota Palu...........................State: Central Celebes Country:

Indonesia ...............................................................

2. Home Telephone: ..............................Mobile No.: +6282193229668 Email:

zhafrancommoditysupplier@gmail.com ........................................................

3. Specify the proof of address submitted for residence address: …………………………………………………….........

4. Permanent Address (if different from above or overseas address, mandatory for Non-Resident Applicant):

..................................................................................................................................................................... …………

FRS Financial Services GmbH, Stiegstrasse. 14, A-6830 Rankweil, Tel. +43 (0) 670 308 0939, Fax +43 (0) 55 22 / 48 888-6, email
info@frs-co.at Gemäß der von der Finanzmarktaufsichtsbehörde, Otto-Wagner-Platz 5, 1090 Wien, erteilten Konzession ist die FRS Financial Services GmbH zur Beratung, Verwaltung
und Vermittlung von Finanzinstrumenten gemäß § 3 Abs. 2 Z 1 und Z 3 WAG 2003 sowie §3 Abs. 2 Z 2 WAG 2018 berechtigt. Firmenbuch Nr. 178747p, UID-Nr. ATU46486707

Copyright © 2022 FRS Financial Services GmbH

 Loan Application Form

City/town: ..........................................State: ................................Country: ...............................................................

DECLARATION
I hereby declare that the personal details furnished above are true and correct to the best of my knowledge and belief and I
undertake to inform you of any changes therein, immediately. In case any of the above information is found to be false or untrue
or misleading or misrepresenting, I am aware that I may be held liable for it.

Signature of the Applicant Date: (dd/mm/yyyy)

Corporate Information
Please fill this form in ENGLISH and in BLOCK LETTERS your company details.

A. COMPANY DETAILS

1. Name of Company: ...................................................................................................................................................

2. Date of incorporation: ...................................... (dd/mm/yyyy) & Place of incorporation: ......................................

3. Date of commencement of business: (dd/mm/yyyy) ....................................................................

4. a. Registration No.: ...................................... b. Tax Identification #.: ...........................................................

5. Status (please tick any one)

Private Limited Co./ Public Ltd. Co./ Body Corporate/ Partnership/ Trust/ Charities/ NGO’s/ FI/ FII/ HUF/ AOP/ Bank/
Government Body/ Non-Government Organization/ Defense Establishment/ BOI/ Society/ LLP/ Others (please
specify)

B. ADDRESS DETAILS

1. Address for correspondence: .....................................................................................................................................

City/town: ..........................................State: ................................Country: ...............................................................

2. Office Tel.: ...................................... Fax: ...................................... Email: .............................................................

3. Specify the proof of address submitted for correspondence address: .....................................................................

4. Registered Address (if different from above): ............................................................................................................

City/town: ..........................................State: ................................Country: ...............................................................

FRS Financial Services GmbH, Stiegstrasse. 14, A-6830 Rankweil, Tel. +43 (0) 670 308 0939, Fax +43 (0) 55 22 / 48 888-6, email
info@frs-co.at Gemäß der von der Finanzmarktaufsichtsbehörde, Otto-Wagner-Platz 5, 1090 Wien, erteilten Konzession ist die FRS Financial Services GmbH zur Beratung, Verwaltung
und Vermittlung von Finanzinstrumenten gemäß § 3 Abs. 2 Z 1 und Z 3 WAG 2003 sowie §3 Abs. 2 Z 2 WAG 2018 berechtigt. Firmenbuch Nr. 178747p, UID-Nr. ATU46486707

Copyright © 2022 FRS Financial Services GmbH

 Loan Application Form

C. COMPANY SIGNATORIES

# Full Names of Partners/ Directors of Company Job Title

1
2
3

Please Note: You will submit a valid identification document of the entered member. E.g.: International Passport, Company
ID or Driver’s license copies ONLY.
1. Specify the proof of identity submitted for Members: ...............................................................................................

DECLARATION
I/We hereby declare that the corporate details furnished above are true and correct to the best of my/our knowledge and belief
and I/we undertake to inform you of any changes therein, immediately. In case any of the above information is found to be false
or untrue or misleading or misrepresenting, I am/we are aware that I/we may be held liable for it.

Name & Signature of the Applicant Date: (dd/mm/yyyy)

FUNDING REQUEST DETAILS

Amount Required
Loan Tenure
Purpose of Loan

LOAN SECURITY

Details of Collateral Securities Offered, if any, including third party guarantee

1. Collateral: ............................................................................................................................................

2. Value: ...................................... Type of Security: ...........................................................................

FRS Financial Services GmbH, Stiegstrasse. 14, A-6830 Rankweil, Tel. +43 (0) 670 308 0939, Fax +43 (0) 55 22 / 48 888-6, email
info@frs-co.at Gemäß der von der Finanzmarktaufsichtsbehörde, Otto-Wagner-Platz 5, 1090 Wien, erteilten Konzession ist die FRS Financial Services GmbH zur Beratung, Verwaltung
und Vermittlung von Finanzinstrumenten gemäß § 3 Abs. 2 Z 1 und Z 3 WAG 2003 sowie §3 Abs. 2 Z 2 WAG 2018 berechtigt. Firmenbuch Nr. 178747p, UID-Nr. ATU46486707

Copyright © 2022 FRS Financial Services GmbH

 Loan Application Form

a. Third Party Guarantee b. Premium Surety Bond

DOCUMENT CHECKLIST

Checklist Required Documents

1 Executive Summary and Business Plan
2 Company Registration Documents (photocopies)
3 Government Issued ID (International passport bio page, driver’s license and others)
4 Personal/Company Bank Statements, Tax Documents, Company Balance Sheet (if
applicable)

IMPORTANT: Please note; we reserve the rights to withdraw from financing any project or business if we discover
irregularities in filed application, if the nature of business is against the laws of the host country, if your business engages in
arms deals, terrorism and drug (narcotics) related businesses or other prohibited vices.
We reserve the rights to use any of the information provided in this form to conduct due diligence assessment to mitigate
financial risks on the side of the investors, but also the rights of the borrower or partner is protected to the interest of all.

FOR OFFICE USE ONLY

Originals verified and Self-Attested Document copies received

Name & Signature of the Authorized Officer …………………. ………. Date …………… Seal/Stamp

ESG POLICIES AND ASSESSMENT

1 Type of operations associated with your business e.g.

manufacturing / production, warehousing, logistics etc.
2 Does your company derive its revenues from
pornography and prostitution, production, sale or
distribution of weapons, illegal drugs, polychlorinated
biphenyl and asbestos?
3 Please confirm that your company does not derive its
revenues from child labor, environmental pollution or
production of harmful materials to the climate.
4 Does the company have policies that cover ESG
aspects (ESG Policy, Environmental Policy, Health
FRS Financial Services GmbH, Stiegstrasse. 14, A-6830 Rankweil, Tel. +43 (0) 670 308 0939, Fax +43 (0) 55 22 / 48 888-6, email
info@frs-co.at Gemäß der von der Finanzmarktaufsichtsbehörde, Otto-Wagner-Platz 5, 1090 Wien, erteilten Konzession ist die FRS Financial Services GmbH zur Beratung, Verwaltung
und Vermittlung von Finanzinstrumenten gemäß § 3 Abs. 2 Z 1 und Z 3 WAG 2003 sowie §3 Abs. 2 Z 2 WAG 2018 berechtigt. Firmenbuch Nr. 178747p, UID-Nr. ATU46486707

Copyright © 2022 FRS Financial Services GmbH

 Loan Application Form

Safety Policy, Social Policy)?

DECLARATION AND SIGNATURES

I/We hereby declare that the details furnished above and the documents submitted in regards to this application are true
and correct to the best of my/our knowledge and belief and I/we undertake to inform you of any changes therein,
immediately.

In case any of the above information or document(s) are found to be false or untrue or misleading or misrepresenting, I
am/we are aware that I/we may face litigations and financial or material damages sustained as a result of the false
information provided will be demanded.

Name & Signature of the Applicant Date: (dd/mm/yyyy)

IMPORTANT:
Please note; You reserve the rights to withdraw from filling the form due to health issues, company irregularities or
setbacks. The interest of both the borrower and the lender is protected and so cancellation is permitted.

You may also submit other relevant documents later to increase your chances of fair assess of your loan application. We
do not guarantee that the application will be approved for funding. The decision is solely for the risk assessment and
investment team.

FOR OFFICE USE ONLY

Name & Signature of the Authorized Officer …………………. ………. Date …………… Seal/Stamp

FRS Financial Services GmbH, Stiegstrasse. 14, A-6830 Rankweil, Tel. +43 (0) 670 308 0939, Fax +43 (0) 55 22 / 48 888-6, email
info@frs-co.at Gemäß der von der Finanzmarktaufsichtsbehörde, Otto-Wagner-Platz 5, 1090 Wien, erteilten Konzession ist die FRS Financial Services GmbH zur Beratung, Verwaltung
und Vermittlung von Finanzinstrumenten gemäß § 3 Abs. 2 Z 1 und Z 3 WAG 2003 sowie §3 Abs. 2 Z 2 WAG 2018 berechtigt. Firmenbuch Nr. 178747p, UID-Nr. ATU46486707

Copyright © 2022 FRS Financial Services GmbH