Form

Title

First name*

Last name*

Email*

Contacting for business purposes

Date of Birth

Job title

Phone number

Mobile phone number

Linkedin profile

Preferred method of contact*

Please ensure that relevant contact details are completed above

Company name*

Registration number

Additional trading names

Street address*

Postal code*

City/Town*

Country*

Company Website

Date of incorporation

Day/Month/Year

Entity type*

Structure of the business - if "other" please provide details in the description of business section below

Are you regulated?*

Yes

If so, which jurisdiction(s)

Name of regulator(s)

Name of regulated entity

Link to online register entry

LEI

Current trade/network affiliations

Licence type

AR of an authorised network/club?

Name of executing broker's custodian*

If you do not have one, please enter "none" and "n/a" for contact details to follow

Company name of executing broker's custodian*

Street Address of executing broker's custodian*

City/Town of executing broker's custodian*

Postal Code of executing broker's custodian

Country of executing broker's custodian

Email of executing broker's custodian*

Phone number of executing broker's custodian

Description of business

A brief summary of the business, the types of underlying clients and other important relevant information to disclose.

Typical Investor Classification

Select all that apply

Professional - Per se professional clients

Professional - Elective professional clients

Eligible counterparties - Per se eligible counterparties

Eligible counterparties - Elective eligible counterparties

Sophisticated - Certified

Sophisticated - Self-certified

HNW - Certified

Are you tied to or do you work with a specific platform?

If so, please provide details

PEPs*

PEPs Details*

I hereby certify that I have taken out the appropriate levels of business insurance, including but not limited to public and product liability, professional indemnity and employers' liability (where applicable)

I hereby certify that I am able to work, registered to pay and comply with local tax regulations in my jurisdiction

I hereby give consent for Paravene Capital Investment Management Ltd to store the information contained in the document, that I understand may be shared with third party partners

I hereby give consent to be contacted periodically for marketing purposes of other financial products that may be of interest

I hereby give consent for Paravene Capital Investment Management Ltd to carry out their own, or authorise a third party to undergo background checks using publicly available information