INDIVIDUAL INVESTOR APPLICATION FORM (Please note for Corporate, Trust and Institutional Investors a separate application form should be completed and is available from www.dominion-funds.com) The Shares in Dominion CHIC Fund Limited (the “Company”) should be registered in the following name(s): 1. INVESTOR DETAILS Individual Investor 1: Full Name: Date and Place of Birth: d d m m y y y y Nationality: Address and Postcode: Tel.: Fax: E-mail: @ Occupation: Source of funds: Accrued Savings or earnings Sale of Property or Business Other (Please specify) Individual Investor 2: Full Name: Date and Place of Birth: d d m m y y y y Nationality: Address and Postcode: Tel.: Fax: E-mail: @ Occupation: Source of funds: Accrued Savings or earnings Sale of Property or Business Other (Please specify) Address for correspondence if different from above: Tel.: Fax: E-mail: @ Evidence of Identity: I/We hereby apply to invest the amount subscribed above in Shares in the Company subject to the terms of Investors must provide certified copies of passport(s), ID card(s) or drivers licence(s) and a utility bill or a the Offering Memorandum. I/We hereby declare that the Shares in the Company are not being acquired bank/credit card statement less than 3 months old which shows the investor’s residential address quoted in directly or indirectly by or for a “Non-Qualified Person”. I/We acknowledge that the Company reserves section 1. All copies should be legally certified by either the Independent Financial Adviser or other authority the right to reject an application in whole or in part. I/We further declare that having read and understood empowered to certify documents. the Offering Memorandum I/We accept the risk associated with an investment in the Company, have understood the charges applicable to an investment in the Company and declare that I/we have taken Anti-Money Laundering: Please note that in certain circumstances it may be necessary to request additional appropriate professional financial advice and or legal advice. evidence of identification prior to accepting any subscription. Please also note that your funds may not be invested until all identity verification has been completed. For DC Share Class investments only: I/We hereby declare that I/we understand that in choosing to invest in shares of the DC Share Classes that 2. TOTAL AMOUNT OF INVESTMENT I/We will not incur any initial charge on such investment and I/we agree and specifically authorise the Please confirm the currency/currencies of investment by ticking the appropriate box(es) below. Company to transfer Shares to the Manager from my/our holding on a quarterly basis for the first five years EURO USD GBP Minimum investment per Class EUR 7,500.- USD 10,000.- and GBP 5,000. of such investment in order to meet the deferred charge as described in the Offering Memorandum. 3. AMOUNT OF INVESTMENT PER FUND CHIC s DC Class Signature: Date: CHIC s IC Class CHIC US$ DC Class CHIC US$ IC Class CHIC £ DC Class Signature: Date: CHIC £ IC Class Minimum investment per Class EUR 7,500. - USD 10,000. - and GBP 5,000. 6. TO BE COMPLETED BY THE FINANCIAL ADVISER Payment can only be completed by Telegraphic Transfer. Adviser Name: 4. FINANCIAL STATEMENTS Company Name: I/We would request that all financial statements are delivered to me/us by the following method: Method of Issue: Mail Facsimile Address & Postcode: Email (Address if different to section 1) @ Tel.: 5. DECLARATIONS Data Protection Disclosure: Personal information contained in this Application Form will be handled by the Fax: Manager and/or Administrator (acting as Data Processor on behalf of the Company) in accordance with E-mail: @ the Guernsey Data Protection legislation. I/We hereby consent to the processing of my/our information and the disclosure of my/our information to any relevant Guernsey or overseas government agency, the Financial Adviser Code: Investment Manager, the Investment Advisor and where necessary or in the Company’s, the Manager’s Application Code: or the Administrator’s legitimate interest to any company in the Manager’s, the Administrator’s and/or the Investment Advisor’s group of companies or agents of the Manager and/or the Administrator including Please return this Application Form to: companies situated in countries which may not have the same data protection law as Guernsey. I/We Dominion Fund Management Limited consent to the Company disclosing information with regard to this application and any investment from PO Box 660, Tudor House, Le Bordage, St Peter Port, Guernsey, GY1 3PU time to time held by me/us in the Company together with all details concerning such investment (including valuations) to the Financial Advisor referred to at 6. below until such time as the Company receives notice in Tel: +44 1481 734343 | Fax: +44 1481 734353 | www.dominion-funds.com writing to the contrary. I/We also acknowledge that such data may be transported via an open network that is accessible to the public (Internet). The data may also be transmitted across borders without any controls Defined terms used in this Application Form shall have the same meanings as set out in the Company’s and can occur even when both the sender and the recipient are in the same jurisdiction. latest Offering Memorandum.
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