Edward Jones Center for Entrepreneurship & Innovation


	Home Educate Train Fund Events About The Center

Angel Network Information Request

Membership Application and Questionnaire


First Name:
Last Name:
Entity Name (If Applicable):
Your Position (If Applicable):
Street Address:
City:
State:
Zip:
Office Phone:
Home Phone:
Cell Phone:
Preferred Email Address:
Questionnaire
Previous Angel Investment Experience:
Preference of Industries in which to Invest:

After you have submitted you online application, please mail a check for the $500 membership dues to:
Springfield Angel Investors 202 South John Q. Hammons Parkway, Springfield, MO 65806

Requirements


In order to confirm that you meet the requirements to be an Accredited Investor (in accordance with Rule 501(a) of Regulation D of the Securities Act of 1933, as amended), please check one of the following to indicate which qualification is applicable to you.
For Individuals
	A natural person with individual net worth (or joint net worth with spouse) in excess of $1 million.
	A natural person with individual income (without including any income of the Investor's spouse) in excess of $200,000, or joint income with spouse of $300,000, in each of the two most recent years and who reasonably expects to reach the same income level in the current year.
For Entities:
	An entity in which all of the equity owners are Accredited Investors.
	A corporation, partnership, business trust, limited liability company or Section 501(c)3 organization with total assets in excess of $5 million.
	A trust with total assets in excess of $5 million whose purpose is directed by a person who has such knowledge and experience in financial and business matters that he/she is capable of evaluating the merits and risks of prospective investment.
	A broker-dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934. A bank or savings and loan association as defined in Section 3(a) of the Securities Act of 1933, whether acting in its individual or fiduciary capacity.
	An insurance company as defined in Section 2(13) of the Securities Act of 1933.
	An 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. A 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 a plan has total assets in excess of $5 million.
	An employee benefit plan within the meaning of ERISA, provided that the investment decision is made by a plan fiduciary, as defined in Section 3(21) of such Act, which is a bank, savings and loan association, insurance company or registered investment advisor, or that the employee benefit plan has total assets in excess of $5 million; or, if the plan is self-directed, with investment decisions made solely by persons that are Accredited Investors.

Representations


I hereby represent that all the information supplied herein is true, correct and complete as of the date hereof. If I am accepted as a member of the Springfield Angel Network, I agree (1) to notify you immediately of any material change in the foregoing answers and (2) not to provide confidential investment information obtained through Springfield Angel Network to anyone other than my spouse, lawyers, accountants or other professional advisors. I acknowledge that you do not provide me with investment advice.
First and Last Name:
Current Date: