DETAILS OF THE CLAIMANT(S) (“CLAIMANT”): [PLEASE PRINT]LCM Funding Agreement • June 2nd, 2020
CLAIMANT(S) NAME Full Name(s) of individual (s): CLAIMANT’S ADDRESS (Street Address) No. and Street: Town: State: Postcode: Country: CLAIMANT’S POSTAL ADDRESS(write “as above” if the same as street address) No. and Street (or PO Box): Town: State: Postcode: Country: CONTACT NAME (Person to be contacted for inquiries)(write “as above” if the same as CLAIMANT(S) NAME) Contact Name (Title, First Name and Surname): CONTACT PERSON’S POSTAL ADDRESS:(write “as above” if the same as CLAIMANT(S) POSTAL ADDRESS) No. and Street (or PO Box): Town:State: Postcode: Country: CONTACT PERSON’S EMAIL PHONE AND FACSIMILE (Note: We prefer to correspond by Email) Email:Phone (landline): Phone (Mobile): Facsimile: Note: If there is not sufficient space on this page for all the details, please annex a separate page.
