JOIN LEGACY ANGEL NETWORK

Prospective Member Application

Please fill out the following health declaration form in order to participate in our activity. Submissions are valid up to 24 hours prior to the activity.

First Name

Last Name

Email

Phone

Link to online biography (if available)

Have you invested in startups before?

Yes

No

What Skills and/or experience can you offer to the Legacy Angel Network?

Do you live in Florida?

Yes, more than 50% of the time

Yes, but less than 50% of the time

No, but I visit frequently

No, I rarely visit Florida

How many hours per month can you commit to LAN activities?

Less than 1 hour

1- 5 hours

5 - 10 hours

More than 10 hours

How did you hear about LAN?

If referred, please list the name(s) of the members that referred you

Please review the statements below. Checking each box indicates your understanding of and agreemet with the Legacy Angel Network membership guidelines.

I am an accredited investor as defined by the SEC.

I understand that member dues are $3,000 annually and will be automatically renewed unless otherwise notified.

I understand that The Legacy Angel Network is NOT a registered broker dealer, invesment advisor, or financial managment organization.

I understand that The Legacy Angel Network is NOT responsible for the accuracy of materials provided by companies seeking investment.

I understand that The Legacy Angel Network is NOT responsible for the accuracy/appropriateness of company valuations presented by company representatives.

I understand it is my responisibility (as investor) to perform my own due diligence on all companies that I intend to invest in.

Date

Initials

I confirm that the information given in this form is true

Thanks for submitting!

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