Section 12J Investment Form

Please provide a Investor Type.
Please provide a valid Title.
Valid Surname, First and Other Name/s are required.
Yes No
Your Citizenship is required.
Your ID/Passport Number is required.
Valid Surname is required.
Valid Company Type is required.
Your Company registration number is required.
Your Company registration number is required.
Valid Surname is required.
Your Trust Number is required.
Valid Type of Trust is required.
Your Company registration number is required.

Please enter a valid email address for shipping updates.
Please enter a Tax Reference Number.

* Physical address:

Please enter your Physical address.
Please enter your Postal code.

Postal address:

If the same as physical add, please tick here
Please enter your Postal address.
Please enter your Postal code.

If applicable, the individuals name and ID number if acting on behalf of an Investor:

Representatives Name is required.
Representatives ID Number is required.

R
Please enter amount above R100000.00

FATCA disclaimer

Yes No
Do you have tax liabilities or tax residence outside South Africa?
Do you hold any nationalities outside of South Africa?
Are you a United States citizen/person/national?
Are you a Domestic Prominent Influential Person (DPIP) or a Foreign Prominent Public Official (FPPO)?
Are you affiliated to a DPIP or FPPO through a family member and/or an associate?

Business Income
Dividend
Donation
Gift
Interest
Inheritance
Salary
Sale of asset
Savings
Other

Declaration

The Investor (or the individual authorised to act on behalf of the Investor) hereby agrees to the full understanding of the contents of this Application Form. The Investor (or the individual authorised to act on behalf of the Investor) further confirms:

I agree that I have read and understand all the declarations below


* The understanding that should a claim for the Section 12J tax deduction be performed for the subscription price of the Company’s VCC shares then the base cost of the VCC shares when calculating capital gains tax will be reduced to zero.

* That the Company will not be held liable for delays or losses incurred due to incomplete or inaccurate information on the Application Form or insufficient or incorrect submission of FICA information. Annexure A outlines the FICA requirements that must be up to date with the Investor’s broker.

* Reading the Company’s Prospectus and accepts that he/she understands the entire Prospectus.

* The understanding of the fees and the risks associated with making an investment in the shares of the Company.

* The acknowledgement that the Company is an approved Financial Services Provider however is not licenced to provide advice..

* To undertake to advise the Company within 30 days of any change in circumstances which affects the tax residency status identified in section 1 of this Application Form or causes the information contained herein to become incorrect or incomplete and to provide the Company with a suitably updated self-certification and declaration within 90 days of such change in circumstances.

* That all and any funds and/or moneys used to purchase the Company’s shares are not the proceeds of unlawful activities and that the Investor has not contravened any anti-money laundering and tax legislation and shall not be in contravention of the Financial Intelligence Centre Act.

* Not receiving any advice from the Company or a representative of the Company. The Investor has either appointed a registered representative that is not part of the Company to explain this investment, Application Form and the Prospectus or is comfortable to read and understand the aforementioned in the absence of a representative.

* That the Company is permitted to act on the Investor’s behalf.

* That the Company’s mandate will become of force and effect on receipt of a signed Application Form, FICA information, Declaration of Source of Funds by the Investor together with the proof of payment of the funds, from the Investor.


Yes No

Would you like a representative of the Company to take you through this form?