Jenson Seed EIS Fund - Clubfinance

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113Investor & Anti-Money Laundering CertificateTo Be Completed By The Investor Without A Financial Adviser (if you wish to applythrough a financial adviser, please ask him/her to complete the form on page 111)I certify to Foresight Group LLP that the answers given below are true, complete and accurateProfessional Client CategorisationIn order for you....................................................................................... [please insert your name] (the “Investor”) toparticipate in the Fund, we must undertake an assessment of your expertise, experience and knowledge soas to give us reasonable assurance, in light of the nature of investments in complying funds such as the Fund,that you are capable of making your own investment decisions and understanding the risks involved. ThisInvestor & AML Certificate requests information to help us undertake this assessment. Additional informationmay be required. We will keep all information provided by you confidential. A clear written warning ofthe protections and investor compensation rights the Investor may lose in being treated as an electiveprofessional client is set out in the schedule hereto.Please be aware that we are unable to begin investing your contribution until we have received thecompleted and signed form. Please ensure that you have signed this form before returning it to:Jenson Seed EIS Fundc/o Reyker Securities plc, 17 Moorgate, London, EC2R 6AR.Investment ObjectivesPlease review the investment objectives of the Fund, set out on page 22 of the Information Memorandumand schedule 1 of the Investor’s Agreement and tick the box below to confirm that you are aware of andunderstand these objectives and that they are consistent with your own personal financial objectives inrespect of your potential investment in the Fund.Your ProfessionPlease state your current profession, or, if you are retired, your previous profession:Please state your first language below if it is not English:
Investment ExperienceYour experience and understanding of various types of investments is a factor in determining the suitabilityof the Jenson Seed EIS Fund for you. Please put a number in each box in the table below to indicate thenumber of years of personal experience you have had with particular types of shares.Types of sharesLarge quoted companiesSmaller quoted companiesAIM-listed or unquoted companiesYears of ExperienceAnti-Money Laundering Due DiligenceWe are required under the Money Laundering Regulations 2007 to verify the identity of all investors in the Fundand we therefore require copies of (a) an identity document and (b) a proof of address document from you.Please supply a certified copy of one document from list 1 (proof of identity) and one document from list 2(proof of address)1 Identity document – please enclose a certified copy (see below for details of who can certify yourdocuments) of one of the following documents and put a tick in the relevant box:Current Passport or national identity card115SEIS, EIS or VCT investmentsNumber of previous shareholdingsFull driving licence (both parts)In what capacity have you had this experience? (please tick)ShareholderDirector2 Proof of address – please enclose a certified copy (see below for details of who can certify your documents)of one of the following documents and put a tick in the relevant box:Recent bank statement (less than three months old)Adviser/consultant/auditorOther, please specifyCredit reference agency reportUtility bill (less than three months old)Please list any current company directorships you hold/have held in the last five yearsCurrentLast five yearsFull driving licence (both parts) (if not used for proofof identity)CERTIFIED COPIESHave you been in a network or syndicate of business angels for at least six months prior to today’s date?(please tick and, if applicable, provide details)YesCopies should be certified by a regulated professional person such as a solicitor, bank manager, financialadviser or accountant or, alternatively, by a person in a position of responsibility such a teacher or doctor whois known to the applicant. The documents requiring certification should be identified on the back as follows: “Icertify that this is a true copy”. Please print the name, address, telephone number and capacity in which signed(e.g. doctor, company director) of the authorising person and ensure that the document is signed by them.NoDetailsFOR FORESIGHT GROUP LLP INTERNAL USE ONLYWe are required under the Money Laundering Regulations 2007 to verify the identity of all investors in the Fundand we therefore require copies of (a) an identity document and (b) a proof of address document from you.Please supply a certified copy of one document from list 1 (proof of identity) and one document from list 2(proof of address)Assessment CompletedOther relevant details and/or experience that might berelevant to our assessment of you as a professional clientin relation to investment in the Jenson Seed EIS Fund,whose objective will be to invest in start-up and early stagecompanies. Have you had experience of such companieseither directly or as an investor?DateAssessment criteria met?
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ClubfinanceADDITIONAL ANTI-MONEY LA
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Jenson Seed EIS Fund - Clubfinance

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