• Investor Form

    Investor Form

  • PERSONAL INFORMATION

  • Mobile Phone Number
  • Home/ Work Phone Number
  • Gender*
  • Marital Status*
  • Date of Birth (mm/dd/yyyy)*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Passport Issued (Date)
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date Passport Expires
     / /
    2 digit month, 2 digit day, 4 digit year

  • PRESENT ADDRESS

  • IF YOU ARE CURRENTLY INSIDE THE USA, PLEASE PROVIDE THE FOLLOWING

  • Visa Issuance Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • I-94 Issuance Date (attach copy)
     / /
    2 digit month, 2 digit day, 4 digit year
  • Visa Expiry Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • I-94 Expiry Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date of Last Entry Into US
     / /
    2 digit month, 2 digit day, 4 digit year

  • DETERMINATION OF ACCREDITED INVESTOR STATUS (TO COMPLY WITH U.S. REGULATIONS, YOU MAY BE REQUESTED TO SUPPLY DOCUMENTS TO SUPPORT YOUR NET WORTH AND INCOME).

    The undersigned is an accredited investor by reason of at least one (1) of the following (select YES for every item that applies):

  • FAMILY

    Spouse

  • Gender
  • Date of Birth (mm/dd/yyyy)
     / /
    2 digit month, 2 digit day, 4 digit year
  • Passport Issued (Date)
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date Passport Expires
     / /
    2 digit month, 2 digit day, 4 digit year

  • Children

  • EMPLOYMENT

  • Start Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • FINANCIAL CONDITION

  • DETERMINATION OF ACCREDITED INVESTOR STATUS (TO COMPLY WITH U.S. REGULATIONS, YOU MAY BE REQUESTED TO SUPPLY DOCUMENTS TO SUPPORT YOUR NET WORTH AND INCOME).

    The undersigned is an accredited investor by reason of at least one (1) of the following (select YES for every item that applies):

  • 1. My net worth (either individually or with my spouse, if any), including home(s), investments and all property and other assets, is at least US$1,000,000.
  • 2. My individual annual income was at least US$200,000 in each of the two most recent years, and I expect such income in the current year.
  • 3. My annual income, jointly with my spouse, was at least US$300,000 in each of the two most recent years, and I expect such income in the current year.

  • SECURITY INFORMATION

  • Have you or your spouse ever filed for Bankruptcy?*
  • Have you or your spouse ever been convicted of a crime?*
  • Have you or your spouse ever been denied entry to the United States?*
  • Have you previously applied for a U.S. immigrant or non-immigrant visa and been denied?*
  • Will you be able to clearly document that the cash required to make your investment comes from a lawful source?*

  • VERIFICATION

  • Please supply copies of two (2) of the following for the Applicant/Investor (and Spouse):

    1. Valid government issued drivers license including photograph.
    2. Valid passport (copy of picture page).
    3. National Identity card if available.
    4. Copy of current US visa (if inside the United States).
    5. Copy of I-94 (if inside the United States).

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  • AUTHORIZATION

  • I hereby acknowledge that the information provided is accurate and truthful as of this date. My submission allows Birch Capital to review the information.

  • DATE (mm/dd/yyyy)*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: