Membership Application Form Please complete the form below to apply for Perth Angels Membership. If you have any questions, please contact us. First Name * Last Name * Email * Phone (Work/Mobile) * Company Website Referred by How much money do you typically invest per year? * How many deals have you been a part of? * Are you involved with any other angel/investment groups? Please list the groups you are active in and briefly describe your involvement. Please indicate the most relevant area of interest you feel you might contribute to as a member of Perth Angels? Deal SourcingScreening DealsBusiness MentorLeading DealsRepresent at EventsServe as Board MemberOthers Are you aware of the $997.00 membership fee PA? *YesNo Can you be available to attend an induction session? *YesNo Would you prefer to do the induction in person or online? *In personOnline What are your key areas of investment interest (i.e. “MedTech" or “Blockchain" etc)? What do you see as your area of industry expertise? What previous positions have you held (i.e. CEO, Board Member, Engineer, etc)? How much do you anticipate investing per year? Are you a service provider (e.g. Legal Services, Accounting, etc)? *YesNo Provide details: Have you been or are you currently the subject of, a defendant in, or, a respondent in any investigation, civil litigation, arbitration, or other action and/or proceedings, in which your professional conduct in either a direct or supervisory capacity was at issue? *YesNo Provide details: Have you been or are you currently the subject of a written complaint regarding your professional conduct in either a direct or supervisory capacity? * YesNo Provide details: Have you been, or are you currently permanently or temporarily prevented from any of the following: (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? * YesNo Provide details: 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 / regulation or any rule promulgated thereunder? * YesNo Provide details: Have you been, or are you currently convicted of: (i) any felony or other crime punishable by more than one year in prison (ii) misdemeanor involving moral turpitude (lying, cheating, stealing, or other dishonest conduct) or (iii) any substantially equivalent crime in any court of law? * YesNo Provide details: Please read and agree to our Member Expectations (PDF) and Code of Conduct (PDF) Documents. DECLARATION Membership is a privilege and to qualify for membership please note you will be asked to identify your accredited investor status as per the definition of "Sophisticated Investor" defined in Section 708 of the Corporations Act upon any investment made as a member of the group. I am an accredited investor (if relevant) under the rules and regulations of [governing body, country]. I have such knowledge and experience in financial and business matters to be capable of evaluating the relative merits and risks of anyinvestment. I agree to abide by the terms and rules of Perth Angels: By-laws Code of Conduct Confidentiality requirements Membership requirements Membership agreement I understand that Perth Angels is not a venture fund, investment bank, broker/dealer, or any other form of investment adviser; the group does not provide advice, recommendation, or any other indication of appropriateness or inappropriateness for a particular investment. Perth Angels does not endorse any investment opportunity and makes no independent investigation to verify information provided by companiessubmitting to the group for a presentation or otherwise, and; Makes no representation or warranty regarding the same. I must conduct my own analysis and due diligence to determine the appropriateness of any investment I make in any company to which I am introduced through Perth Angels. I recognize and agree that the group is not liable for any investment decision that I make, as a result of being a member of Perth Angels. The choice to use and the manner of utilisation of information and knowledge gained through the group is my individual and personal choice. I understand that Perth Angels meetings are not an offer to sell, or solicitation to buy any security by the group or any other entity. I agree to pay the annual membership dues as set by Perth Angels. I declare that I have read and agree to the terms and conditions listed in the box above. I declare that the information I have given on this form is complete and correct and that I have not made any false or misleading statements.