BANSEA Membership Application

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Membership type *

Details of each membership types in this weblink: http://tiny.cc/bmtypes

Individual: Member (800 SGD / Year)

Individual: Adjunct member (149 SGD / Year)

Individual: Youth member (25 SGD / Year)

Corporate (1999 SGD / Year)

Corporate Sponsor (2999 SGD / Year)

Adjunct Corporate (999 SGD / Year)

Full Name: *

Email Address: *

Address:

(Optional)

Contact Number: *

Invests as:

Optional: E.g. Individual, Company, etc

LinkedIn Profile URL:

(Optional)

Website/Blog:

(Optional)

Referred By:

(Optional)

Why would you like to join BANSEA? *

Please describe your motivation(s)

How much capital do you typically invest or intend to invest per year? *

(Optional)

Less than 25'000 SGD

Between 25'000 SGD and 50'000 SGD

Between 50'000 and 100'000 SGD

Between 100'000 and 500'000 SGD

More than 500'000 SGD

How many deals have you participated in?

(Optional)

Are you involved with any other angel/investment groups?

(Optional)

Interests:

(Optional)

Deal Sourcing

Screening Deals

Business Deals

Leading Deals

Represent at Events

Serve as Board Member

Social Activities

Other:

Investment Interests

Optional: Indicate industry interests, ex. “Biotechnology” or “Clean Technology”

Industry Expertise

Optional Which industries do you have experience in?

What previous positions have you held?

Optional Ex. CEO, Board Member, Engineer…

Are you a service provider?

Optional: Legal Services, Accounting… if yes, please explain how does this fit to BANSEA

Have you been or are you currently the subject of, a defendant in, or respondent in any investigation, civil litigation, arbitration, or other action or proceeding in which your professional conduct, in either a direct or supervisory capacity, was at issue? *

Yes

Have you been or are you currently permanently or temporarily prevented from: (i) acting as a person required under any law or regulation (i.e., investment advisor, broker, dealer, etc.); (ii) acting as an affiliated person or employee of any entity required to be registered under any law or regulation (i.e., investment company, bank, etc.); or (iii) trading on any securities or contract market? *

Yes

Have you been or are you currently the subject of a written complaint regarding your professional conduct in either a direct or supervisory capacity? *

Yes

Have you been or are you currently found to have aided, abetted, counseled, commanded, induced, or procured the violation by any person or entity of any securities or commodities-regulated law or regulation or any rule promulgated there under? *

Yes

Have you been or are you currently convicted of (i) any felony or other crime punishable by more than one year in prison, or (ii) a misdemeanor involving moral turpitude (lying, cheating, stealing, or other dishonest conduct) or any substantially equivalent crime in any court of law? *

Yes

I confirm and declare that I am an accredited investor as defined in Section 4A(1)(a) of the Securities and Futures Act (Cap. 289)

If applicable.

I declare being an accredited investor

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This form was created inside of BANSEA.