STAN Application

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STAN Application

  1. 1. STAN Accredited Investor Profile Form CONFIDENTIAL Please complete this form and Fax to Erica Bishop at 210 458-2529. Please call Erica at 210 458-2713 prior to sending the Fax to insure confidentiality, or you may mail the information to Ms. Erica Bishop South Texas Angel Network (STAN) c/o SATAI P.O. Box 461106 San Antonio, TX 78246 The following information will assist STAN/SATAI to better understanding you and your investment preferences as they relate to early-stage technology investing. This information will not be sold, bartered or distributed and will remain with SATAI in confidence in its office. A. BIOGRAPHICAL INFORMATION Name: ________________________________________ Address1: ________________________________________ Address2: ________________________________________ City, State, Zip ____________________ ________ __________ Phone Number: ________________________________________ Alternate or Cell Phone: ________________________________________ Fax Number: ________________________________________ Business / Institution Name: ________________________________________ Title: ________________________________________ Retired? Yes No Preferred email: ________________________________________ B. ACCREDITED INVESTOR INFORMATION I am an Accredited Investor according to one of the following rules promulgated by the: Securities Act of 1933, Rule 501 of Regulation D (See Last Page) My individual income was in excess of $200,000 in each of the two most recent years or my joint income with my spouse was in excess of $300,000 in each of those years, and I reasonably expect an income in excess of $200,000 or a joint income with my spouse in excess of $300,000 in the current year. My net worth, or joint net worth with my spouse, is in excess of $1,000,000. From Reg. § 230.501 below, I qualify according to paragraph ________. 1 of 4 6/10/2010
  2. 2. STAN Accredited Investor Profile Form CONFIDENTIAL C. ANGEL/SEED/VENTURE CAPITAL INVESTMENT PROFILE Please indicate your personal history making investments in a private technology companies: Company Stage / Type # of Investments Aggregate Investments ($) Seed or Pre-seed $ Early or Mid $ Late / Pre-IPO $ Limited Partnership Interests or LLC Memberships in Private Equity Funds $ (non Oil, Cattle or Real Estate) My tolerance for risk in making direct investments in a private technology companies is: Very High - I understand the high-risk / high-reward nature of private investing and am willing to accept these risks to make equity investments I am comfortable with. Limited - I understand the high-risk / high-reward nature of private investing, but am only willing to make investments in abnormally compelling circumstances. Low - I understand the high-risk / high-reward nature of private investing and am not willing to make investments. Unknown / Unsure – I am unsure or vaguely familiar with the high-risk / high-reward nature of private investing and would consider making investments after learning more. I understand that a direct investment in a private company involves a significant degree of risk in the growth of my investment’s value and the opportunity for my investment to reach liquidity? Yes Somewhat No The average sized individual direct investment in a private, early-stage technology company I would feel comfortable making is: $ _______________ / per investment The number of investments I would feel comfortable making a year is: _____ / per year When making investments, I want to be an active Angel Investor by taking part in one or more of the following: doing my own due diligence, sitting on the board, mentoring the management team, taking a pro-bono executive position, etc: Yes No, see below When making investments, I prefer to be a passive investor and rely on the expertise of my trusted peers to perform due diligence and mentor / monitor the management team: Yes No 2 of 4 6/10/2010
  3. 3. STAN Accredited Investor Profile Form CONFIDENTIAL When making investments, I will only consider technology companies in the following industries (check all that apply): Semiconductors & Information Technology (software, hardware, and/or peripherals) Biotechnology, Life Sciences, Medicine & Healthcare Energy, Refining & Processing (does not include speculative oil and gas drilling) Aerospace & Defense Industrial, Advanced Manufacturing & Transportation Chemicals & Advanced Materials Nanotechnology & Micro-Electromechanical Systems (“MEMS”) I am willing to make private, early-stage investments but only in “low tech” industries such as retail, restaurants, professional services, etc: Yes No Optional: The percent of my net worth or portfolio I dedicate to all alternative assets is: ______% The percent of my alternative asset allocation I would dedicate to early-stage technology private investing is: ______% Reg. § 230.501. (a) Accredited investor. “Accredited investor” shall mean any person who comes within any of the following categories, or who the issuer reasonably believes comes within any of the following categories, at the time of the sale of the securities to that person: (1) Any bank as defined in section 3(a)(2) of the Act, or any savings and loan association or other institution as defined in section 3(a)(5)(A) of the Act whether acting in its individual or fiduciary capacity; any broker or dealer registered pursuant to section 15 of the Securities Exchange Act of 1934; any insurance company as defined insection 2(13) of the Act; any investment company registered under the Investment Company Act of 1940 or a business development company as defined in section 2(a)(48) of that Act; any Small Business Investment Company licensed by the U.S. Small Business Administration under section 301(c) or (d) of the Small Business Investment Act of 1958; any plan established and maintained by a state, its political subdivisions, or any agency or instrumentality of a state or its political subdivisions, for the benefit of its employees, if such plan has total assets in excess of $5,000,000; any employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974 if the investment decision is made by a plan fiduciary, as defined in section 3(21) of such Act, which is either a bank, savings and loan association, insurance company, or registered adviser, or if the employee benefit plan has total assets in excess of $5,000,000 or, if a self-directed plan, with investment decisions made solely by persons that are accredited investors; (2) Any private business development company as defined in section 202(a)(22) of the Investment Advisers Act of 1940; 3 of 4 6/10/2010
  4. 4. STAN Accredited Investor Profile Form CONFIDENTIAL (3) Any organization described in section 501(c)(3) of the Internal Revenue Code, corporation, Massachusetts or similar business trust, or partnership, not formed for the specific purpose of acquiring the securities offered, with total assets in excess of $5,000,000; (4) Any director, executive officer, or general partner of the issuer of the securities being offered or sold, or any director, executive officer, or general partner of a general partner of that issuer; (5) Any natural person whose individual net worth, or joint net worth with that person’s spouse, at the time of his purchase exceeds $1,000,000; (6) Any natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with that person’s spouse in excess of $300,000 in each of those years and has a reasonable expectation of reaching the same income level in the current year; (7) Any trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the securities offered, whose purchase is directed by a sophisticated person as described in § 230.506(b)(2)(ii); and (8) Any entity in which all of the equity owners are accredited investors Signed: ___________________________________________ Printed Name: __________________________________________ Date: ___________________________ 4 of 4 6/10/2010

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