Jenson Seed EIS Fund - Clubfinance

ClubfinanceADDITIONAL ANTI-MONEY LAUNDERINGINFORMATION 1Please complete all the fields below in block capitals, using black or blue ink. Please remember to sign the form.For some types of investment we need to collect additional information to satisfy anti-money laundering requirements.Name of investment(s) you are applying for: Amount(s) invested (£):Origin of funds (tick all that apply): Personal savings Savings & investment income Earned income (e.g. salary/bonus) Inheritance Sale of investments / other assets Compensation payment Lottery / betting win GiftOrigin of funds (tick all that apply) - continued: Policy claim / maturity Other (please specify)___________________________________________Purpose of transaction (tick all that apply): Investment Tax planning Other (please specify)___________________________________________SOURCE OF FUNDS (payment must be from a personal UK bank or building society account in your name) CHEQUE(S) enclosed with application(s) BANK TRANSFER(S) (not all products allow this) – if using this method, please: include an original bank statement less than 3 months old (not printed from the internet),or a cheque crossed through with “VOID”, to support the account used (if not previouslyprovided); and complete the following informationBank / building society:Account holder(s):Account number:Sort code:I confirm that I will be making the application(s) on my own behalf and not as a trustee,nominee, agent or in a fiduciary or any other capacity for any other person(s).Full name:Occupation:Signature:Date:APPLICATION CHECKLISTPlease send to Clubfinance Ltd (PO Box 1036, Hemel Hempstead, Hertfordshire, HP1 2WU) This form Clubfinance Client Declaration Identification documents (if not already sent to Clubfinance) If investing by bank transfer, bank/building society statement (