Business Assistance—Immigrant Investor Program (IMIN)
APPLICATION FOR A NON-REFUNDABLE FINANCIAL CONTRIBUTION
Note This financial contribution application and the documents to be attached hereto must be deposited with a certified financial intermediary (broker or trust company). A list of such financial intermediaries is available from the Investissement Québec website at http://www.investquebec.com/en/
SECTION 1 - IDENTIFICATION OF THE COMPANY
Exact name of the Company submitting the application and any other name used to carry on operations:
NEQ (Québec business number):
Address of head office:
Address of principal office
(if different from head office):
Person Investissement Québec should contact:
Telephone:
Fax:
E-mail:
Address
(if different from head office):
SECTION 2 - INFORMATION ABOUT THE COMPANY
Note: If you already have a business plan that covers the questions in Section 2 below, you may append it to your application and go directly to Section 3.
2.1	Date of incorporation:	Date on which operations began:
(yyyy)	(yyyy)
2.2	Sector of activity of the Company
2.3	Products and services of the Company:
2.4	Target consumer base:
2.5	Competitors:
2.6	Shareholders of the Company
Ownership (list shareholders as well as the number and percentage of shares held in each category) Name Common shares Preferred shares Number % Number %
2.7	Is the Company part of a group made up of a parent company and subsidiaries?	Yes*	No
*If need be, append the list and organizational chart of these companies, along with the most recent financial statements for each.
2.8	Principal executives of the Company
Management	Years of experience
Title	Surname and given name	Degree(s)	in the industry	with the Company
2.9	Description of the project and financing
Project	Financing
Type of expenditure	$	Source of financing	$
Total	Total
Goal of project and impact on the Company if completed:
Site(s) where the project is to be carried out:

If the project includes the acquisition of a building, did the Company sell or rent out (or does it intend to sell or rent out) the currently used building in consideration therefore?
Yes	No	N/A
If applicable, indicate the actual price or market value of the building sold or rented (or to be sold or rented):
2.10	Project timetable
Project commencement date:	Anticipated project termination date:
(Date of first expenditures incurred)	(yyyy-mm-dd)	(Anticipated date of last expenditures to be incurred)	(yyyy-mm-dd)

2.11	Employment (for statistical purposes)
Note: A productivity improvement project can result in a reduction in the number of existing positions
Number of full-time employees before commencement of project:	After project begins:
Number of full-time jobs saved:	(corresponds to the number of positions
likely to disappear within 12 months if the Company’s project is not carried out)
2.12	Sales outside Québec (for statistical purposes)
According to the most recent financial statements (or forecast financial statements if a start-up company):
Volume of the Company’s sales outside Québec: $
Percentage of the Company’s sales outside Québec:	%
SECTION 3 - DOCUMENTS TO ENCLOSE WITH THE APPLICATION
Financial partners’ financing offers duly accepted by the Company; Financial statements (audited or with review engagement report) for the last two fiscal years; Most recent (less than 3 months) “in-house” financial statements; Forecast income statement for the current and subsequent fiscal year; Organizational chart of companies in the group (parent company/subsidiary(ies)), if applicable; Most recent financial statements of each company in the group (parent company/subsidiary(ies), if applicable or consolidated financial statements of the group; Company’s business plan, if available.
Name of signatory	Title of signatory
Signature	Date

SECTION 4 - DECLARATION OF THE COMPANY
Company name:
File no.:	(Reserved for use by IQ Immigrants Investisseurs inc.)
A)	The Company and its representatives agree that Investissement Québec and IQ Immigrants Investisseurs inc. may contact them by electronic means at the e-mail address provided to send information of potential interest to them or to inform them of any commercial or business offer that may be of interest to them.
B)	The Company and its representatives agree not to use Investissement Québec’s name or logo in any way whatsoever and in any paper or electronic format without Investissement Québec’s prior written approval.
C)	The Company authorizes Investissement Québec and IQ Immigrants Investisseurs inc. to exchange with government departments, government agencies, interested financial institutions and personal information agents, including credit agencies, (collectively referred to as “Institutions”) any information or documents needed for the analysis of its application for financing, including this declaration. Without limiting the generality of the foregoing, the Company authorizes any Institution to exchange with Investissement Québec and IQ Immigrants Investisseurs inc. any information or document in its possession needed for the analysis of its application for financing. IQ may collect, communicate and use this type of information to maintain data integrity in its credit assessment systems and its internal credit approval process only, despite the repayment of any financing.
D)	The Company hereby declares that the owners, shareholders or partners of the Company and its related companies as defined by the Taxation Act and their directors are not members of the National Assembly, are not members or employees of Investissement Québec or of IQ Immigrants Investisseurs inc., are not related as defined in the Taxation Act and deal solely at arm’s length with one or more of these persons, with the exception of:
E)	The Company hereby declares that it is not involved in any dispute, legal proceedings or investigation by a government department or a municipal, provincial or federal agency and declares that it is in good standing with these government departments or agencies, in particular the Canada Customs and Revenue Agency and Revenu Québec, with the exception of:
F)	The Company hereby declares that it operates in compliance with all environmental legislation and neither the Company nor the former owners of the Company's assets have used the latter in contravention of environmental legislation; moreover, no proceedings have been instituted (or are anticipated) and no notice has been received in respect of an alleged violation of environmental legislation, except for:
G)	The Company hereby declares that it does not store any hazardous materials as defined in the Regulation respecting hazardous materials (CQLR, chapter Q-2, r.32) and that it does not possess a tank used to store fuel, except for: (in the case of a tank, specify its capacity and whether it is located on the surface or underground)
H)	The Company hereby declares that, with respect to the project for which it is seeking the financial intervention of Investissement Québec or IQ Immigrants Investisseurs inc., it has not received, nor will it receive, other government financial assistance, whether municipal, provincial or federal, with the exception of:
I)	The Company declares that its Québec business number (NEQ) is:
J)	The Company certifies that it has not made any transaction with a partnership, corporation or person with which it is not dealing at arm’s length or to which it is related as defined in the Taxation Act concerning expenses related to the project or with a lessee, with the exception of:
K)	The Company declares that its shareholders, owners and members and those of any related companies are not related to a company or to the shareholders, owners or members of such company that has been granted financing by Investissement Québec, IQ Immigrants Investisseurs inc. or Société générale de financement du Québec (SGF), with the exception of:
L)	The Company hereby declares that its key officers or shareholders whose guarantee could be required under the terms of the requested financing authorize Investissement Québec to contact third parties, particularly financial institutions, creditors, personal information agents etc., in order to obtain and exchange all the personal information required to establish knowledge of their financial situation. For this purpose, said individuals shall provide, on request, their address, their date of birth and any other information deemed relevant by Investissement Québec for that purpose. In addition, at the request of Investissement Québec, the Company shall ensure that said key officers or shareholders complete and sign the document entitled Personal Balance Sheet and Other Financial Information.
M)	The Company hereby declares that it has not modified the contents of this application.
I,	, the, undersigned, duly authorized representative of
the Company,hereby certify that the above information and all documents provided to Investissement Québec are (or will be) complete and true in all respects.
Title of signatory	Signature	Date