Angel Sign-up Form

Please complete the following information to qualify as an "accredited" investor. After you have completed the information below, click to submit the annual $95 membership fee. You will then receive a private passcode to use when ordering the Venture Profile summary, "elevator pitches" outlining the detailed information and/or business plans on any of the current ventures registered for funding.

*Angel Membership Profile:

*Fields with an asterisk are mandatory.

*First Name:
*Last Name:
Title:
Company:
*Address:
*City:
*State:
*Zip Code:
Country:
*Phone:
Fax:
*E-mail:
Website:
Contact:

Years in Business:

How did you find us?    Click to select... Personal Referral Business Associate Word of Mouth E-mail Contact Search Engine Link from other web site

Which industries you are most interested in:

Aerospace		Aircraft
Agricultural		Automotive
Bio-Tech		Communications
Computer Software		Computer Hardware
Construction		Consumer Products
Defense		Education
Electronics		Energy
Entertainment		Environment
Film/Television		Financial Services
Food		Forestry/Fish
Gaming		Health/Fitness
Industrial		Insurance
Inernet/E-commerce		Lodging/Resorts
Manufacturing		Marine
Medical		Natural Resources
Oil/Gas		Pharmaceuticals
Publishing/Printing		Real Estate/Development
Security		Space Technology
Technology		Textiles
Transportation		Any of the above

Other:

Countries of interest:

United States	Canada
United Kingdom	Western Europe
Carribean	Eastern Europe
South America	South Pacific
Australia	Malaysia
Hong Kong	China
New Zealand	Japan
Singapore	Worldwide

*Minimum amount you have previously invested:

Click to select... Under $500,000 Under $1,000,000 $3,000,000 = $5,000,000 $5,000,000 = $10,000,000 $10,000,000 = $25,000,000 Over $25,000,000

*Maximum amount you have previously invested:

Click to select... Under $500,000 Under $1,000,000 $3,000,000 = $5,000,000 $5,000,000 = $10,000,000 $10,000,000 = $25,000,000 Over $25,000,000

*Current portfolio value:

Click to select... Under $500,000 Under $1,000,000 $3,000,000 = $5,000,000 $5,000,000 = $10,000,000 $10,000,000 = $25,000,000 Over $25,000,000

Comments:
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*Declaration of Accreditation: No investment is guaranteed. Because Venture Capital is considered high risk investment, in order to pre-qualify as an "accredited" Angel investor and receive specific information on current projects, you must fall within the legal definition of the Securities and Exchange Commission (SEC) in Rule 501 of Regulation D, as an individual with one of the following criteria. Again, if you have any further questions about these qualifications, please visit the Securities and Exchange Commission's web site at www.sec.gov.

You are legally responsible for the truth of this declaration and can be held responsible for any false and/or incorrect information submitted:

Individually, or jointly with my spouse, I/we have a net worth of more than $1 million dollars valued at cost, net of encumbrances.

I have an income of more than $200,000 annually for the past two consecutive years.

My spouse and I have had a combined income of more than $300,000 annually for the past two consecutive years.

Please include me in periodic e-mail notices that offer advance notice of and discounts for investment conferences, seminars and events.

Welcome to the Island Connections Angel Network! We look forward to working with you.