Apply as Investor - Kansas Angels

Angel Investor Registration

* = required

First Name

Last Name

Email Address

Address

Address Line 2 (Apt. No, Etc.)

City

State

Postal Code

Phone

Fax

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.

Yes

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