Membership Application

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Referral to Alliance How did you learn about the organization? Are You known to any members?:
Business Experience Describe your business experience and significant accomplishments. Include companies, positions held and dates. Describe the business skills you have that would be of benefit to the organization:
Private Investment Experience List and describe specific investments you have made in private companies and describe any active roles you have taken (mentor, director, incubator):
Board Experience List public and private boards that ou have serve on and the dates of service:
Education:
Affiliations:
Family, Personal Interests:
Accredited Investor Status Do you currently meet the requirements for being an accredited investor? In the United States, for an individual to be considered an accredited investor, they must have a net worth of at least one million US dollars or have made at least $200,000 each year for the last two years ($300,000 with his or her spouse if married) and have the expectation to make the same amount this year.	Yes No
Investment Experience Indicate the areas where you have had prior experience (Check all that apply):	Originated Deals Served on Boards Due Diligence - Lead Effort Attended Deal Forums	Negotiated/Structured Deals Reviewed Business Plans Due Diligence - Participated
Industry Technology Investment Experience Indicate the areas where you have had prior experience (Check all that apply):	Communications, Networking Software Optics Semiconductors, Equipment e-Commerce Internet Software/Database Information Services Medical Devices, Equipment Biopharmaceuticals Other Healthcare Energy, Environmental Publishing, Media Manufacturing Aviation Retail Professional Services	Computers, Peripherals Electronics, Components Test & Measurement Internet Business Services Internet Infrastucture Internet Content Other Information Technology Medical Information Systems Healthcare Services Specialty Materials, Chemicals Financial Services Education, Training Industrial Products Consumer Products, Services Real Estate Other
Industry Technology Investment Interest Indicate the areas where you have have a current investment interest (Check all that apply):	Communications, Networking Software Optics Semiconductors, Equipment e-Commerce Internet Software/Database Information Services Medical Devices, Equipment Biopharmaceuticals Other Healthcare Energy, Environmental Publishing, Media Manufacturing Aviation Retail Professional Services	Computers, Peripherals Electronics, Components Test & Measurement Internet Business Services Internet Infrastucture Internet Content Other Information Technology Medical Information Systems Healthcare Services Specialty Materials, Chemicals Financial Services Education, Training Industrial Products Consumer Products, Services Real Estate Other
Geographic Preference for Investments Indicate the geographic area which you prefer to invest:	In My Region Only State of Kansas and Surrounding States	Entire State of Kansas
Operating Experience Indicate operating positions you have held (Check all that apply)	CEO VP Marketing VP Operations CTO/CIO VP Manufacturing Partner - Accounting Partner - Other Services	COO VP Sales VP Engineering CFO Partner - Law Firm Partner - VC Firm Board Member
Functional Experience Indicate the areas where you have strong functional expertise (Check all that apply):	General Management Fund Raising Marketing – Consumer Advertising Sales – Direct, Retail Hardware Development Manufacturing Logistics Finance, Accounting Legal, Agreements	Strategic Planning Organizational Development Marketing – B2B Sales – OEM, Major Account International Sales, Marketing Software Development Operations Quality Information Technology Negotiations
Planned MVA Involvement Indicate the areas where you expect to contribute (Check all that apply):	Originating Deals Serve on Boards Due Diligence - Lead Effort Screening Process	Negotiate/Structure Deals Due Diligence - Participate Lead Screening Process
Legal Filings: List and explain any litigation (as plaintiff or defendant) either personal or business during the past ten years. List and explain any FTC, SEC or other Federal/State or other regulatory proceedings filed against you. List and explain any bankruptcy filings, either personal or for an entity for which you have served as an officer or director.
Investment Expectations: How many investments and in what amounts would you expect to make in deals in a 24 month period? On average, how many hours per week would you expect to devote to organization activities? What other contributions might you make to the organization?
May we disclose that you are a MVA or SEKVA angels member in news articles and PR?	Yes No
May we list your contact information on the secured, member-only section of the web site?	Yes No
As a member of the organization, you will also become a member of the Angel Capital Association, North America’s professional alliance of angel groups. Would you like to receive the Angel Capital Association’s quarterly e-newsletter?	Yes No
Annual Account Maintenance Fees	By selecting the submit button, applicant acknowledges membership carries an annual $250 fee payable to Midwest Venture Alliance for active membership. If member should invest in a deal and choose to become an inactive member, by clicking submit the applicant acknowledges inactive membership requires a $100 annual maintenance fee payable to Midwest Venture Alliance.