Request for Securities Based Loan Quote

For a loan quote please print out and complete this form, and send back along with a copy of the broker statement for the securities listed below.  Please include only the position page/s of the securities statement.  We do not need the activities sheet/s. Please fax to 310-668-7157 or email to anita@sbpiservices.com

Please let us know how you learned about our Securites Based Loans:

_____________________________________________________________

Borrower Information

Name:  ________________________________________________

Phone:  ________________________________________________

E-Mail Address: _________________________________________

Requested Loan Amount:  $ _________________

Desired Loan Term: ___ 3 yr      ___ 5 yr      ___ 7 yr      ___ 10 yr

Number of Shares: ______________

Name of Securities: _________________________________

Approximate Value of Each Share: $ ____________

Stock Symbol (if known): _____________________