Investment Form Investment InfoInvestment Accreditation INVESTMENT INFOPlease confirm the following investment details: Company: DELEX HEALTHCARE GROUPInvestment SizeINVESTING ENTITYAdd another investing entity Individual A Trust A Firm or FundEntity NameHow is the investing entity accredited? I have more than $5M USD (or equivalent) in investments I have between $2.1M and $5M USD (or equivalent) in net assets I have between $1M and $2.1M USD (or equivalent) in net assets I have Income of $200k (or $300K jointly with spouse) for the past 2 years and expect the same this year I am a Series 7, Searies 65, or Series 82 holder and my license is active and in good standingSIGNATORY INFOFirst NameLast NameEmailDate of BirthSSS/TIN/Passport NumberAddressAddress Line 1Address Line 2CityStateZip CodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweFUNDINGPayment Method Pay with Card (Stripe) Pay with PayPal Offline PaymentPay with Card (Stripe)Stripe test mode activatedSIGNINGI agree to the closing documents' provisions, including: I hereby certify, to the best of my knowledge, that the information provided above is complete and correct. I understand that I am investing in a single-company fund (LLC) investing in Delex Healthcare Group Fund, not directly in Delex Healthcare Digital Transformation Fund. I don't have direct investor rights (e.g. I can't contact Delex Healthcare Transformation Fund directly and may not be able to participate in future rounds). I will pay 20% total carry (to Delex Healthcare Group Fund). I understand that certain other investors may pay more or less carry at the discretion of Delex Healthcare Group. The syndicate will pay its own out-of-pocket setup costs. Out-of-pocket setup and admin fees will be paid by the syndicate before investing in Delex Healthcare Group Fund. Fee totals are dependent on the total syndicate raise, typically ranging between 2-8%. When direct investors in Delex Healthcare Group Fund must vote or give legal approval, in Delex Healthcare Group will make decisions on behalf of the fund. Delex Healthcare Group reserves the right to reject any investment in the fund. I understand that my subscription amount is not guaranteed and the final investment amount accepted by the fund may be less than my desired subscription amount. Excess amounts will be returned to me. I agree in Delex Healthcare Group Investor Disclosure, Terms of Service and Privacy PolicyPreviousNextINVESTMENT ACCREDITATIONPls answer truthfullyAre you an Accredited Investor? Yes No I'm not sure**Subject upon approvalAccredited Investor Definition I made $200,000 or more in each of the 2 most recent years, and I believe that I will make as much this year. I have income with my spouse that exceeds $300,000 for each of the last 2 years, and I expect it will exceed that again this year. I have individual net worth, or joint net worth with my spouse, that exceeds $1,000,000 today excluding my primary residence. Terms of Use I acknowledge the following: I understand that investing is highly risky and acknowledge that I may lose 100% of my investment. I understand that investments in private companies are illiquid and cannot easily be resold until it is publicly listed. I understand that Delex does not offer investment advice or guarantee and that I must conduct my own due diligence. INVESTOR QUESTIONNAIREHow many companies have you invested? 0 1-10 10-20 20+Which best describes your typical investment size? $5,000 $25,000 $50,000 $100,000+How would you describe your goals for investing with Delex Healthcare Group? (please rank 1-3, where 1 is your top priority)Diversify your portfolio: Generate financial returns:Invest in healthcare causes or disease(s) you care aboutHow much do you anticipate investing with DHG? Less than $25,000 $25,000 - $100,000 More than $100,000Tell us about yourself Previous Submit Form