Start-Up Investor Conflict of Interest Disclosure Form

Investor Information

Full Name Email Address Investor Company / Affiliation

Investment Details

Start-Up Name Proposed Investment Amount

Conflict of Interest Disclosure

Please disclose any actual, potential, or perceived conflicts of interest with this start-up (financial, personal, professional, or other): Have you, your immediate family, or your affiliated companies previously invested in, advised, or have any direct relationship with the start-up or its founders?

Yes No

If yes, please describe the relationship:

Additional Disclosures

Any other relevant disclosures:

Signature Date