Application and Client Information Form

Date: {{current_date}}

For the purchase of shares in the closed alternative investment fund.

APPLICATION

Applicant details

Company name: {{legal_entity_details.company_name}}
Registration number: {{legal_entity_details.registration_number}}
Country of registration: {{legal_entity_details.registration_country}}
Email: {{legal_entity_details.email}}
Settlement account number: {{legal_entity_details.account_number}}
Bank name: {{legal_entity_details.bank_name}}
Bank address: {{legal_entity_details.bank_address}}

CLIENT INFORMATION FORM

Number of shares and amount

Number of subscription certificates (nominal value of one certificate is 100 EUR): {{investment_details.shares_count}}
Investment amount (minimum investment amount - 5000 EUR): {{investment_details.investment_amount}}

By signing this application, I confirm that I have read the information and documents uploaded with the project in investor room, including the management rules and rules of operation and agree to their terms.
I hereby confirm that the information provided in this application is true. {{confirmation_checkboxes.confirmation_2}}
I confirm that the investment fund units will be issued after receiving payment to the bank account. {{confirmation_checkboxes.confirmation_3}}

Anti-money laundering form

1. Information about the client

Company name: {{client_company_name}}
Company type: {{client_company_type}}
Registration number: {{client_registration_number}}
Date of registration (incorporation):{{client_registration_date}}
Licence type: {{client_license_type}}
Issue date: {{client_license_issue_date}}
Regulatory authority: {{client_license_regulatory_authority}}
NACE 2.0 code: {{client_nace_code}}
Legal (registered) address: {{client_legal_address}}
Are the actual and the legal (registered) addresses the same: {{client_addresses_same}}
Actual address: {{client_actual_address}}
Phone number: {{client_telephone}}
E-mail: {{client_email}}

CEO and members of the management board

{{#each director_details}}

Name: {{director_name}}
Same: {{director_surname}}
Citizenship: {{citizenship}}
Passport (upload document): {{passport_upload}}

{{/each}}

2. Information about client's representative

Name: {{representative_details_legal.representative_name}}
Surname: {{representative_details_legal.representative_surname}}
Basis of representation: {{representative_details_legal.representation_basis}}
Upload document confirming basis of representation: {{representative_details_legal.representation_document}}

3. Information on the ultimate beneficial owner(s):

Client has ultimate beneficial owner(s): {{has_beneficial_owners}}

{{#ifCond has_beneficial_owners "==" "yes"}}

Ultimate beneficial owner details

{{#each beneficial_owners}}

Name: {{ubo_name}}
Surname: {{ubo_surname}}
Citizenship: {{citizenship}}
UBO occupation: {{ubo_occupation}} {{#ifCond ubo_occupation "==" "other"}}{{other_occupation}}{{/ifCond}}
Passport copy: {{passport_copy}}
Ultimate Beneficial Owner Controls: {{control_method}}
Percentage of shares: {{percentage_shares}}
Control is exercised: {{direct_control}}
Type of indirect control: {{indirect_control_type}}
Exercises the control in what way: {{other_control_method}}

{{/each}} {{/ifCond}}

4. Information on a politically exposed person:

Beneficial owner is not politically exposed person
The beneficial owner is a close family member of a politically exposed person
The beneficial owner is a politically exposed person’s close associate
The beneficial owner is a politically exposed person

{{#ifCond politically_exposed_person "==" "family_pep"}}

Name: {{pep_details.pep_name}}
Surname: {{pep_details.pep_surname}}
Civil servant or working in: {{pep_details.pep_institution}}
Position: {{pep_details.pep_position}}
Relationship with politically exposed person: {{pep_relation_details.relationship}}

{{/ifCond}} {{#ifCond politically_exposed_person "==" "associate_pep"}}

Name: {{pep_details.pep_name}}
Surname: {{pep_details.pep_surname}}
Civil servant or working in: {{pep_details.pep_institution}}
Position: {{pep_details.pep_position}}
Relationship with politically exposed person: {{pep_relation_details.relationship}}

{{/ifCond}} {{#ifCond politically_exposed_person "==" "is_pep"}}

Name: {{pep_details.pep_name}}
Surname: {{pep_details.pep_surname}}
Civil servant or working in: {{pep_details.pep_institution}}
Position: {{pep_details.pep_position}}

{{/ifCond}}

5. Information regarding business activity:

Client's economic activity is performed in (country/countries): {{business_countries}}

Type of Client’s business activity:

Organizing gambling
Providing cash transportation services
Acting as an intermediary in real estate transactions
Trading in precious metals and gemstones
Trading in weapons or ammunition
Providing services related to virtual currencies
Providing money services (e.g., settlement cashiers, currency exchange points, cash transfer agent or other service providers offering cash transfer options)
{{other_activity_description}}

6. Countries of residence of main business partners, contractors (at least 3):

{{#each cooperation_partner}}

Person type: {{person_type}}
Company name: {{company_name}}
Registration number: {{registration_number}}
Country of registration: {{registration_country}}
Country of operations: {{operations_country}}
First name: {{partner_name}}
Last name: {{partner_surname}}
ID or passport number: {{id_passport_number}}
Country of issuance: {{issuance_country}}
Country of residence: {{residence_country}}
Nature of cooperation: {{cooperation_nature}}

{{/each}}

7. Information on origin of the funds used:

Source of funds used in the investment: {{#ifCond funds_origin "==" "other"}} Other income {{/ifCond}} {{#ifCond funds_origin "==" "client_activity"}} Economic activity of the client or its company {{/ifCond}} {{#ifCond funds_origin "==" "borrowed_funds"}} Borrowed funds {{/ifCond}}
Business activity description: {{business_activity_description}}
The name of the economic activity provider: {{business_name}}
Economic activity provider registration number: {{business_registration_number}}
Name of lending institution: {{lender}}
Country(-ies) of source of income: {{income_source_countries}}

8. Information on sanctions

Are you or the ultimate beneficial owner(s) subject to international and/or national sanctions? {{subject_to_sanctions}}

{{#ifCond subject_to_sanctions "==" "yes"}}

Sanctions details

{{sanctions_details}} {{/ifCond}}

9. Professional client status

I confirm that I have been recognized as a professional client as defined in clause 124.1 Financial Instruments and Capital Markets Law of Latvia.
I confirm that I would like to be recognized as a professional client with respect to investing in start-up companies through purchase of shares in alternative investment fund.

{{#ifCond professional_client_status "==" "professional"}}

Institution that recognized you as a professional client: {{institution_recognition}}

{{/ifCond}}

Final confirmations

I confirm that the Client, the Client’s related parties involved or otherwise related to the Assignment, their country of origin, their main place of interests or business activities are not designated persons or territories under any economic or other sanctions enacted by the United Nations, the European Union, Estonia, Latvia, Lithuania or the United States of America, unless explicitly provided otherwise in Section 9 above.
I confirm that I am authorized to sign this document.
I confirm that this document and any annexes attached thereto contain all required information and the data provided are complete, correct and not misleading.
I undertake to inform the lawyer (attorney) immediately, but not later than within 10 (ten) days, about any changes to the data mentioned here.

ANNEX I

DEFINITION OF UBO AND PEP

Ultimate Beneficial Owner: The Ultimate Beneficial Owner of a business is either a natural person who owns 25% or more of the share capital or shares with voting rights, including an interest acquired indirectly (if services are aimed to be received from BY office then – 10%), or – failing that – the natural person who controls the business, such as the management board.

Politically Exposed Person: A natural person who in Latvia, Lithuania, Estonia, other EU or EEA member state, Belarus or third country holds or has held prominent public office, including a higher official of the public authority (for example, head of state), head of government, minister, vice-minister or deputy minister, deputy to deputy minister if such an office exists, state secretary or other high level government official, a chancellor of the parliament, government or a ministry; a member of the parliament or a member of similar legislative entity; a member (judge) of the Supreme Court, the Constitutional Court or any other supreme judicial authority whose decisions are not subject to appeal; a mayor of a municipality, head of the municipal administration or other high level municipal official; a member of the management body of the supreme institution of state audit or control, or the chair, deputy chair or member of the board or council of the central bank; an ambassador, a chargé d’affaires, a chargé d’affaires ad interim, a special envoy and minister plenipotentiary or high-ranking military officer; a member of the management or supervisory body of a public undertaking, a public limited company or a private limited company whose shares or part of the shares carrying more than 1/2 of the total votes at the general meeting of shareholders of such companies are owned by the state; a member of the management or supervisory body of a municipal undertaking, a public limited company or a private limited company whose shares or part of the shares carrying more than 1/2 of the total votes at the general meeting of shareholders of such companies are owned by the state, and which are considered as a large enterprises in terms of the (Lithuanian) Law on Financial Statements of Entities; a director, a deputy director or a member of the management or supervisory body of an international organisation or international intergovernmental organisation; a leader, a deputy leader or a member of the management body of a political party, or occupies a position included to the list of persons who are related to Foreign Public Officials, Officials of International Organisations and list of state positions determined by the President of the Republic of Belarus, adopted by order of the State Control Committee of the Republic of Belarus of 29 December 2016 No. 27.

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