Northern 3 VCT PLC Application Form - Clubfinance
Northern 3 VCT PLC Application Form - Clubfinance
Northern 3 VCT PLC Application Form - Clubfinance
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<strong>Northern</strong> 3 <strong>VCT</strong> <strong>PLC</strong><br />
<strong>Application</strong><strong>Form</strong><br />
<br />
Makeyourchequeorbanker'sdraftpayableto"<strong>Northern</strong>3<strong>VCT</strong><strong>PLC</strong>"andcrossed"A/CPayeeonly"andreturnthisformas<br />
soonaspossibleto<strong>Northern</strong>3<strong>VCT</strong><strong>PLC</strong>,NorthumberlandHouse,PrincessSquare,NewcastleuponTyneNE18ER.Theclosingdateforthe<br />
Offerwillbe5.00pmonThursday5April2012(unlessfullysubscribedearlier).<br />
<br />
1<br />
Titleandnameinfull<br />
Permanentaddress<br />
<br />
<br />
<br />
Postcode<br />
<br />
Daytimetel<br />
<br />
Emailaddress<br />
<br />
<br />
Dateofbirth<br />
NationalInsuranceNo<br />
<br />
IamapplyingforOfferSharesasfollows: 2011/12taxyear £ <br />
<br />
orsuchlessersumforwhichthisapplicationmaybeacceptedontheTermsandConditionsof<strong>Application</strong>setoutinPartVofthisdocument.<br />
Pleasesendmeacertificateconfirmingmyentitlementto<strong>VCT</strong>taxreliefs.<br />
<br />
BYSIGNINGTHISFORMIHEREBYDECLARETHAT:(i)Ihavereadtheenclosedtermsandconditionsofapplicationandagreetobeboundbythem;<br />
(ii) I will be the beneficial owner of the Offer Shares in <strong>Northern</strong> 3 <strong>VCT</strong> <strong>PLC</strong> issued to me pursuant to this application; (iii) to the best of my<br />
knowledgeandbelief,theparticularsIhavegivento<strong>Northern</strong>3<strong>VCT</strong><strong>PLC</strong>arecorrect;and(iv)mysubscriptioncomprisestheamountsetoutinbox<br />
2aboveplusanycommissionwaivedonmybehalfforextrashares.<br />
<br />
Ifthisformiscompletedandsignedbyanauthorisedfinancialadviseroranyotherpersonapartfromtheinvestor:<br />
Bysigningthisformonbehalfoftheindividualwhosedetailsareshownabove,Imakeadeclaration(onbehalfofsuchindividual)onthetermsof<br />
subparagraphs(i)to(iv)above.<br />
<br />
<br />
HMRevenue&Customsmayinspectthisapplicationform.Itisaseriousoffencetomakeafalsedeclaration.<br />
<br />
<br />
<br />
2<br />
3<br />
<br />
Signature<br />
<br />
<br />
<br />
Date / /<br />
<br />
<br />
Authorisedintermediariesshouldstampandcompletethisbox<br />
Contactname:<br />
<br />
Firmname:<br />
<br />
FSANo.:<br />
<br />
Emailaddress:<br />
<br />
<br />
<br />
<br />
Address:<br />
<br />
Postcode:<br />
<br />
Duecompletionoftheagent'sboxindicatesthattheagentisdulyauthorisedtotransactinvestmentsofthistypeundertheFinancialServicesandMarketsAct2000.<br />
ForOfficialUseOnly<br />
<br />
Antimoneylaundering <br />
CHAPS <br />
<br />
<br />
Tel.:
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