Investor Application

To be considered for membership, member applicants must complete and submit the online Membership Application. Applicants are promptly contacted and interviewed by a member of the MVA Membership Committee. Fill out the form below to complete your application.

Name
Address
City, State, Zip
This Address is
Email
Business Phone
Cell Phone
Company
Title
How did you learn about the organization? Are you known to any members?
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.
List and describe specific investments you have made in private companies and describe any active roles you have taken (mentor, director, incubator)
List public and private boards that you have served on and the dates of service.
Education
Affiliations
Personal Interests
Do you currently meet the requirements for being an accredited investor as defined in Rule 501 of Regulation D by the U.S. Securities and Exchange Commission?
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
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 Infrastructure
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
Indicate the areas where you 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 Infrastructure
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
Indicate the geographic area which you prefer to invest (Check all that apply)
In My Region Only
State of Kansas and Surrounding States
Entire State of Kansas
Indicate operating positions you have held (Check all that apply)
CEO
VP Marketing
VP Operations
CTO/CIO
VP Manufacturing
Partner – Accounting
Partner – Other Services
Other
COO
VP Sales
VP Engineering
CFO
Partner – Law Firm
Partner – VC Firm
Board Member
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
Other
Indicate the areas where you expect to contribute (Check all that apply)
Originate Deals
Serve on Boards
Due Diligence – Lead Effort
Screening Process
Negotiate/Structure Deals
Review Business Plans
Due Diligence – Participate
Lead Screening Process
Other
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.
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 month 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?
May we list your contact information in the secured, member-only section of the Web site?
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?
By clicking the accept button, applicant acknowledges membership carries an annual $275 fee payable to Midwest Venture Alliance for active membership. If a member should invest in a deal and choose to become an inactive/affiliate member, by clicking submit the applicant acknowledges inactive/affiliate membership requires a $175 annual maintenance fee payable to Midwest Venture Alliance.
Accept annual account maintenance fees

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