INDIVIDUAL INVESTOR APPLICATION FORM by ihd49167

VIEWS: 39 PAGES: 2

									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.

								
To top