Loan Request

Your Information

How Did You Hear About Us?

[group other-referral-field] Other:

[/group] [group agent-referral-field] Referral Name:

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Your Name:

Your Email Address:

Your Phone (if possible, include both home and mobile numbers)

Amount Requested:

Currency:

Use of Funds:

Collateral Property Details

Property Location: Please include Province, Town, and District

Approx. Land Area: (pick square meters or square feet)

Approx. Construction Area M2: (pick square meters or square feet)

Property Value:

Currency:

Property Description: Please include the age and condition of the property

What is/are your Land Survey (plano catastrado) or Lot number(s)? (optional)

I authorize Gap Equity Loans or its designee to verify the details provided on this form as to the validity and accuracy of the information provided.

I authorize Gap Equity Loans to disclose relevant details to its network of private investors, via means including but not limited to an "Investor Alert" e-mail, in order to secure a loan.

I authorize Gap Equity Loans to place relevant details to the GapInvestments.com web site for private investors to view and inquire, in order to secure a loan.