INVESTOR REGISTRATION
FORM
YOUR ATTENTION IS DRAWN TO THE DECLARATIONS ON THE FOLLOWING PAGE
1.
NAME
2.
COMPANY NAME (if appropriate)
3.
ADDRESS
POSTCODE
4.
UNITARY AUTHORITY
TELEPHONE NUMBER(S) work:
fax:
mobile:
home:
5.
E-MAIL ADDRESS
6.
For individual membership, please give your date of birth
Would you like to receive the Bulletin by email?
Yes
No
____ /__/_
Please tick the box if you would like to receive information relating to services or in relation to marketing events or
sponsored events operating by xénos, Finance Wales or entities associated with Finance Wales.
7.
How Involved in the proposition would you like to be? Full-time
8.
What stage(s) of development are you interested in?
Seedcorn
Company for sale
Early stage
9.


Part-time
Not at all

Start-up
Expansion
MBO/MBI

Amount available for investment: £
(This should be the amount that, if asked, your Accountant would confirm you have readily available)
10. Maximum/minimum investment which you would consider making: Max:£
Min:£
11. Are you prepared to join others in syndicated investments?
 No
Yes
12. Do you have an existing portfolio of investments?
 No
Yes
13. Would you be interested in investing in companies which are in financial difficulties?
 No
Yes
14. How did you initially hear about xénos?
15. Area(s) of Wales in which you would consider Investment
15 What area(s) of expertise are available?
(Please circle one or more)
Other (please specify)
North
Mid
West
South
General
Distribution
Export
Finance
Management
Manufacturing
Human Resources
Marketing
Procurement
Production
Property
Strategy
Technical
Sector selection guide
In this section please indicate the sectors you would consider investing in and/or have
experience.
Investment
Experience
Automotive and transport
Biotechnology
Construction
Creative media and entertainment
Education and training
Electronics
Energy and renewables
Environmental and recycling
Engineering
Financial and professional services (legal, accountancy,
architectural, consultancy
Food and drink
Healthcare and medical
Hotel and restaurant
Information technology (software, hardware)
Internet and e-commerce
Manufacturing
Printing and publishing
Property
Retail and consumer goods
Small product manufacturing
Telecommunications
Tourism, travel and leisure
Other (please specify)
NOTE: The information supplied will be entered on to our database and used as a basis for the automatic matching of investors with
investment opportunities.
SPORTING & LEISURE INTERESTS QUESTIONNAIRE
SPORTING & LEISURE INTERESTS
Please tick as many boxes as you like:
Antiques
Motor Cross
Athletics
Motor Racing
Automobiles
Opera
Clay Pigeon Shooting
Orienteering
Cricket
Ornithology
Fine Dining
Rambling
Fine Wines
Rugby
Golf
Sailing
Horse Racing
Soccer
Ice Hockey
Theatre
Literature
Vintage Cars
Other (please specify)
NOTICE TO INVESTORS
xénos provides an information service to exchange data between unquoted companies and potential investors. It does not advise
on the merits or risks of investment and is not authorised to carry on regulated activities under the Financial Services and
Markets Act 2000 but rather is an exempt body under Article 40 of the Financial Services and Markets Act 2000 (Exemption)
Order 2001.
Investment, whether in new or existing businesses, carries high risks, as well as the possibility of high rewards. It is highly
speculative and potential investors should be aware that no established market exists for the trading of shares in private
companies and as such investments are not readily realisable.
Before investing in a project about which information is given, potential investors are strongly advised to take advice from a
person authorised under the Financial Services and Markets Act 2000 who specialises in advising on investments of this kind.
Whilst xénos will take reasonable steps to ensure that the information it makes available concerning proposals requiring capital,
whether in documentary form or as a verbal briefing, is neither inaccurate nor misleading, it is reliant upon the information
provided by the firms concerned and no independent verification or investigation is carried out by xénos, because of the number
of applications handled and in the context of the resources available. Accordingly, it will be the responsibility of potential
investors to undertake their own due diligence in respect of information provided by xénos.
Please note on occasions a potential investee may require us not to disclose information about them to one or more investors.
Accordingly no responsibility can be accepted by xénos or any participating agency for any damage or loss of whatsoever nature
due to negligence, disclosure or non-disclosure or any direct or indirect cause occasioned by an investment in any business
registered with xénos where the investment arises as a result of information provided under the xénos scheme. The contents of
this form, and of any further communication with you from xénos in this regard, has not and will not be approved by an
authorised person (as defined in the Financial Services and Markets Act 2000).
To join the xénos Investor Register please complete this registration form and send it with the stipulated fee to the address
below. The fee is for a one year subscription and should the service be cancelled or membership ceased a pro -rata amount of
the fee will be returned to you. xénos reserves the right to decline an application and in this event the registration form and fee
will be returned to you. Following the first year of membership an annual renewal fee of £75 plus VAT is payable to xénos ,.
Membership may be terminated by xénos at any time in its absolute discretion.
DECLARATION
I confirm that I would like xénos to contact me about potential investment opportunities and will notify xénos in writing
if I no longer want such contact from xénos.
I agree to hold confidential any information provided to me by, or about, any business introduced to me by xénos or any xénos
affiliated agency and shall not publish, copy or disclose to any other third party any such information other than to profess ional
advisers, for the purpose of considering my monetary investment, and shall ensure that any third party to which I pass such
information agrees to keep such information in confidence and trust. In no event shall I be deemed to have acquired any right or
interest to any such information which shall remain the sole property of the company to which it relates.
I consent to xénos or any xénos affiliated agency holding personal data provided by me on computer and processing it for the
purposes of the xénos scheme and making such disclosures as are necessary in relation to the xénos scheme save to the
extent that I notify xénos to the contrary.
I undertake that I will not solicit business from any company seeking investment nor in any way use any introduction made und er
the xénos scheme for my own commercial gain, other than envisaged by the terms of the scheme.
I shall not give investment advice (as such term is defined in the Financial Services and Markets Act 2000) to any third party
under the scheme.
I have provided full written details to xénos of any unspent criminal convictions (excluding motoring offences for which a fine
and/or 3 penalty points were imposed) I have. I further agree to inform xénos immediately should I gain any such criminal
convictions whilst I am a member of the xénos Investor Register. I acknowledge that if I have not disclosed any such criminal
convictions to xénos, then xénos shall be entitled to terminate my membership of the xénos Investor Register with immediate
effect.
I undertake to notify xénos as soon as is reasonable practical and in any event within 21 days of any investment made by
me as a result of this service.
I have read and agree to the above terms and conditions and I hereby request to be entered onto the xénos Investor Register,
on the above terms and conditions and enclose my cheque for £210.00 (inclusive of VAT) or for renewal of membership
£90.00 (inclusive of VAT).
I confirm that to the best of my knowledge the information given in this form is correct.
Signed
__________________________________________________________________________Dated_______________________
FOR AND ON BEHALF OF:
If returning this form electronically please mark box ‘x’ to confirm acceptance of our terms and conditions
Please return completed forms to:
xénos, the Wales Business Angel Network Ltd
1 Capital Quarter
Tyndall Street
Cardiff
CF10 4BZ
T:
F:
E:
W:
029 2033 8144
029 2080 1760
[email protected]
www.xenos.co.uk
Statement for certified high net worth individual
I declare that I am a certified high net worth individual for the purposes of the Financial Services and
Markets Act 2000 (Financial Promotion) Order 2005.
I understand that this means:
(a) I can receive financial promotions that may not have been approved by a person authorised by the
Financial Conduct Authority;
(b) the content of such financial promotions may not conform to rules issued by the Financial Conduct
Authority;
(c) by signing this statement I may lose significant rights;
(d) I may have no right to complain to either of the following—
(i) the Financial Conduct Authority; or
(ii) the Financial Ombudsman Scheme;
(e) I may have no right to seek compensation from the Financial Services Compensation Scheme.
I am a certified high net worth individual because at least one of the following applies (a) I had, during the financial year immediately preceding the date below, an annual income to the value
of £100,000 or more;
(b) I held, throughout the financial year immediately preceding the date below, net assets to the value of
£250,000 or more. Net assets for these purposes do not include —
(i) the property which is my primary residence or any loan secured on that residence;
(ii) any rights of mine under a qualifying contract of insurance within the meaning of the Financial
Services and Markets Act 2000 (Regulated Activities) Order 2001; or
(iii) any benefits (in the form of pensions or otherwise) which are payable on the termination of my
service or on my death or retirement and to which I am (or my dependants are), or may be, entitled.
I accept that I can lose my property and other assets from making investment decisions based on
financial promotions.
I am aware that it is open to me to seek advice from someone who specialises in advising on investments.
Name……………………………………………………….
Signature……………………………………………………
If returning this form electronically please mark box ‘x’ to confirm acceptance of our terms and conditions
Date………………………….
Statement for self-certified sophisticated investor
I declare that I am a self-certified sophisticated investor for the purposes of the Financial Services and
Markets Act (Financial Promotion) Order 2005.
(a) I can receive financial promotions that may not have been approved by a person authorised by the
Financial Conduct Authority;
(b) the content of such financial promotions may not conform to rules issued by the Financial Conduct
Authority;
(c) by signing this statement I may lose significant rights;
(d) I may have no right to complain to either of the following
(i) the Financial Conduct Authority; or
(ii) the Financial Ombudsman Scheme;
(e) I may have no right to seek compensation from the Financial Services Compensation Scheme.
I am a self-certified sophisticated investor because at least one of the following applies (a) I am a member of a network or syndicate of business angels and have been so for at least the last six
months prior to the date below;
(b) I have made more than one investment in an unlisted company in the two years prior to the date
below;
(c) I am working, or have worked in the two years prior to the date below, in a professional capacity in the
private equity sector, or in the provision of finance for small and medium enterprises;
(d) I am currently, or have been in the two years prior to the date below, a director of a company with an
annual turnover of at least £1 million.
I accept that I can lose my property and other assets from making investment decisions based on
financial promotions.
I am aware that it is open to me to seek advice from someone who specialises in advising on investments.
Name…………………………………………………….
Signature…………………………………………………
If returning this form electronically please mark box ‘x’ to confirm acceptance of our terms and conditions
Date………………………...