Home Angel Investor Registration * = required First Name Last Name Email Address Physical Address Address Address Line 2 (Apt. No, Etc.) City State Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick Newfoundland New Hampshire New Jersey New Mexico New York North Carolina North Dakota Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming None of These Postal Code Mailing Address Address Address Line 2 (Apt. No, Etc.) City State Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick Newfoundland New Hampshire New Jersey New Mexico New York North Carolina North Dakota Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming None of These Postal Code Phone Social Security Number I qualify as an “accredited investor” as defined under Regulation D Rule 501 of the SEC regulations because (Check the applicable statement below) I have an individual net worth or joint net worth with my spouse in excess of $1,000,000. I have had an individual income in excess of $200,000 in each of the last two calendar years and I reasonably expect an individual income in excess of $200,000 for the current calendar year. NOTE: If you are buying jointly with your spouse, you must each have an individual income in excess of $200,000 in each of these years in order to check this box. My spouse and I have had a joint income in excess of $300,000 in each of the last two calendar years and I reasonably expect a joint income in excess of $300,000 for the current calendar year. I understand that a person who serves as an executive, officer, employee, vendor or independent contractor of the business in which an otherwise qualified cash investment is made is not an angel investor and such person shall not qualify for the issuance of tax credits for such investment. I attest that I do not serve in any of these rolls for the company I am investing in. Yes I understand that I can only invest in a company through a permitted entity. An investment through any other entity will result in no tax credits being issued for my investment. I have reviewed the Angel Investor information found at https://www.kansasangels.com/Angels. If investing through a permitted entity I understand I will be required to submit the entity’s CAP table, operating agreement (with the sole purpose of the entity listed as being for investment; no other purpose will be eligible), and proof of initial investment to the permitted entity from my personal account for my ownership percentage. I understand if the initial investment was not from my personal account the entity is not eligible to receive tax credits through this investment account. Yes I understand if I wish to transfer my tax credits, I and the transferee will need to submit a Kansas Tax Clearance that is less than 30 days old to qualify. If a Kansas Tax Clearance cannot be issued, I understand that I cannot offer my credits for transfer. Yes Cancel