Associate Application Form

PROCESS: Kindly complete and sign this subscription form and give it to an authorized representative of Coopérative Society SEEDS-AFRICA (Social Entrepreneurship & Enterprise Development Strategies) either by mail or a scanned version by email together with photocopy of your ID/passport and proof of payment. In order to validate your subscription, you must telephone one of the authorized persons above to receive a document number and a validation number (overleaf) thus confirming your payment and subscription are officially registered.
Once the Board of Directors has approved your subscription, you will receive your certificate as Associate and confirmation of the number of social parts subscribed. Should your subscription not be accepted, all your investment will be promptly returned to you.

If you wish to propose a project or other information, kindly annex it herewith

Associate Application Form

We hereby request to become a member of the cooperative society SEEDS-AFRICA (Social Entrepreneurship &
Enterprise Development Strategies) and we decide to subscribe

Social Parts with a nominal value of CHF 100.- (One Hundred Swiss Francs) with agio of thirty percent (30%) for an
emission price of CHF 130.- (One hundred and thirty Swiss Francs) each thus representing a total of Swiss Francs
(CHF)

In favour of Société Coopérative SEEDS-AFRICA bank account:

• Account name: SEEDS-AFRICA

• BIC TRWIBEB1XXX

• IBAN BE65 9672 3183 3396

• Bank name and address: Wise, Avenue Louise 54, Room S52 Brussels 1050 Belgium

Personal details and domicile:

Title
MrMissMrs
First Name (required)

Surname/Family Name (required)

Address: (required)

Place and Date of birth (required)

City (required)

Postal Code (required)

Country (required)

Your Email (required)

Nationality, ID or passport number (required)

Scanned ID or Passport (jpg, png, pdf - 2Mb maximum)

Phone number(s) (required)

Sponsor Name (required)

Sponsor email

If moral person, Name of organization

Name of authorized person representing the organization:

Copy of original decision as annex (jpg, png, pdf - 2Mb maximum)

Organisation address

Organisation City

Organisation Postal code/ZIP

Organisation Country

Organisation Website

Scanned proof of payment (jpg, png, pdf - 2Mb maximum)

I have read, I understand and I approve the STATUTES to become a member of the Coopérative Society SEEDS-AFRICA (Social Entrepreneurship & Enterprise Development Strategies), a venture capital company; all or part of my investment may be lost. By my signature, I confirm that I am making this investment in my name and for my benefit:
or on behalf of the organization

Today

Signature(s) - please attach your scanned signature(s) (jpg, png, pdf - 2Mb maximum)