QUALIFYING INVESTOR

I acknowledge that one of the following circumstances apply to me (please indicate): *

(a) I am/we are applying for Units at a value of at least $1,000,000 under this Application Form.(b) I have/we have net assets of at least $2.5 million and had a gross income for each of the last two financial years of at least $250,000 per year, and I am/we are applying for Units in the Fund for a purpose other than for use in connection with a business.(c) I am entitled to receive small-scale offerings and understand that acceptance of this application must be completed in line with exclusions afforded it under the Corporations Act.(d) I am/we are a ‘professional investor’ as defined in the Corporations Act *.

If paragraphs (a) and (b) apply, please ensure you have the Accountant’s Certificate completed.

* If you consider yourself a “Professional Investor” please contact the Issuer on the number provided in order to complete the appropriate forms.

Please specify

Please specify *

CONTACT DETAILS

Your Email Address *

Full Name *

Contact Phone Number *

APPLICATION CHECKLIST

Individual Entity Application
Information you will need to complete the Application Form:

Full name of each applicant investor
Tax Details - If you are an Australian resident for tax purposes, please provide your tax file number (TFN) or reason for exemption. If you are an Australian resident and do not provide your TFN, or reason for exemption, you will be taxed at the highest marginal tax rate plus the Medicare levy. Residential address (PO Box not accepted) of each applicant investor
A valid email address and mobile number
Proof that individual investors are 18 or older
Date of birth of each applicant investor
For Identity Verification, you will need to provide: an Australian Drivers Licence, Passport, Medicare Card, Australian Visa, Proof of Residence and Australian State or Territory Proof of Age Card
Sources of funds and wealth must be identified
Bank statement showing the Bank Account Name, BSB and Account number of the applicant.

If your investment is below $500,000.00, the applicant must provide a Wholesale Investor Certificate issued by a qualified accountant. For additional information, please visit ASIC’s website.
Australia's Anti-Money Laundering and Counter-Terrorism Financing (“AML/CTF”) legislation oblige us to collect Identification Information from prospective Investors (this includes beneficial owners). The online ID Facility, World-Check One, provides the opportunity to complete the identity verification electronically. For further information on World-check One, please visit the World-check One website.

Power of Attorney
Applications submitted under a power of attorney must be accompanied by an original certified copy of the power of attorney document and a specimen signature of the relevant attorney(s).

Sole Trader Entity Application
Information you will need to complete the Application Form:

Full name of each applicant investor
Tax Details - If you are an Australian resident for tax purposes, please provide your tax file number (TFN) or reason for exemption. If you are an Australian resident and do not provide your TFN, or reason for exemption, you will be taxed at the highest marginal tax rate plus the Medicare levy. Residential address (PO Box not accepted) of each applicant investor
Residential address (PO Box not accepted) of each applicant investor
A valid email address and mobile number
Proof that individual investors are 18 or older
Date of birth of each applicant investor
For Identity Verification, you will need to provide: an Australian Drivers Licence, Passport, Medicare Card, Australian Visa, Proof of Residence and Australian State or Territory Proof of Age Card
Sources of funds and wealth must be identified

Bank statement showing the Bank Account Name, BSB and Account number of the applicant.
If your investment is below $500,000.00, the applicant must provide a Wholesale Investor Certificate issued by a qualified accountant. For additional information, please visit ASIC’s website.
Australia's Anti-Money Laundering and Counter-Terrorism Financing (“AML/CTF”) legislation oblige us to collect Identification Information from prospective Investors (this includes beneficial owners). The online ID Facility, World-Check One, provides the opportunity to complete the identity verification electronically. For further information on World-check One, please visit the World-check One website.

Joint Investment Entity Application
Information you will need to complete the Application Form:

Full name of each applicant investor
Tax Details - If you are an Australian resident for tax purposes, please provide your tax file number (TFN) or reason for exemption. If you are an Australian resident and do not provide your TFN, or reason for exemption, you will be taxed at the highest marginal tax rate plus the Medicare levy. Residential address (PO Box not accepted) of each applicant investor
Residential address (PO Box not accepted) of each applicant investor
A valid email address and mobile number
Proof that individual investors are 18 or older
Date of birth of each applicant investor
For Identity Verification, you will need to provide: an Australian Drivers Licence, Passport, Medicare Card, Australian Visa, Proof of Residence and Australian State or Territory Proof of Age Card (all applicants)
Sources of funds and wealth must be identified

Bank statement showing the Bank Account Name, BSB and Account number of the applicant.
To apply for a joint investment account with us, you will require a joint bank account in the name of all investors
If your investment is below $500,000.00, the applicant must provide a Wholesale Investor Certificate issued by a qualified accountant. For additional information, please visit ASIC’s website.
Australia's Anti-Money Laundering and Counter-Terrorism Financing (“AML/CTF”) legislation oblige us to collect Identification Information from prospective Investors (this includes beneficial owners). The online ID Facility, World-Check One, provides the opportunity to complete the identity verification electronically. For further information on World-check One, please visit the World-check One website.

Partnership Entity Application
Information you will need to complete the Application Form:

Full name of Partnership
Business trading name (if applicable)
Tax Details - If you are an Australian resident for tax purposes, please provide your tax file number (TFN) or reason for exemption. If you are an Australian resident and do not provide your TFN, or reason for exemption, you will be taxed at the highest marginal tax rate plus the Medicare levy. Residential address (PO Box not accepted) of each applicant investor
A valid email address and mobile telephone number
Registered Office address (PO Box not accepted)
Principle place of business (PO Box not accepted)
Sources of funds and wealth must be identified
Full name of each Partner/s
Copy or relevant extracts of the partnership agreement, full name of the partnership and any business name(s)used by the partnership.
Regulator information (if applicable)
For Identity Verification, you will need to provide: an Australian Drivers Licence, Passport, Medicare Card, Australian Visa, Proof of Residence and Australian State or Territory Proof of Age Card
If your investment is below $500,000.00, the applicant must provide a Wholesale Investor Certificate issued by a qualified accountant. For additional information, please visit ASIC’s website.

Australia's Anti-Money Laundering and Counter-Terrorism Financing ("AML/CTF") legislation oblige us to collect Identification Information from prospective Investors (this includes beneficial owners). The online ID Facility, World-Check One, provides the opportunity to complete the identity verification electronically. For further information on World-check One, please visit the World-check One website.

Beneficial Owner(s) of a Partnerships

You must provide details of each individual who (directly or indirectly):

owns more than 25% of the Trust / Issued Capital of a Partnership; or Controls the Partnership.

If neither of these applies, we must collect details of the individual who holds the power to appoint or remove the Trustee of the Trust (‘Appointer’).

ID will be in accordance with the individual verification requirements above.

Power of Attorney

Applications submitted under a power of attorney must be accompanied by an original certified copy of the power of attorney document and a specimen signature of the relevant attorney(s).

Company Entity Application
Information you will need to complete the Application Form:

Australian Companies

A current full company search of ASIC databases showing:

the full name of the company.
the ABN/ACN.
the registered office address of the company.
the principal place of business of the company.
Personal Information about Directors
Corporate Bank Account Information
If your investment is below $500,000.00, the applicant must provide a Wholesale Investor Certificate issued by a qualified accountant. For additional information, please visit ASIC’s website.
Australia's Anti-Money Laundering and Counter-Terrorism Financing (“AML/CTF”) legislation oblige us to collect Identification Information from prospective Investors (this includes beneficial owners). The online ID Facility, World-Check One, provides the opportunity to complete the identity verification electronically. For further information on World-check One, please visit the World-check One website.

Foreign Companies

Company’s Certificate of Registration / Incorporation (issued by ASIC or by a Regulatory or Government Authority stating the company type (public or private) and Registration Number; or
Articles of Association stating the Company’s name and type (public or private).
the registered office address of the company.
the principal place of business of the company.

Personal Information about Directors
Corporate Bank Account Information
If your investment is below $500,000.00, the applicant must provide a Wholesale Investor Certificate issued by a qualified accountant. For additional information, please visit ASIC’s website.
Australia's Anti-Money Laundering and Counter-Terrorism Financing (“AML/CTF”) legislation oblige us to collect Identification Information from prospective Investors (this includes beneficial owners). The online ID Facility, World-Check One, provides the opportunity to complete the identity verification electronically. For further information on World-check One, please visit the World-check One website.

Beneficial Owner(s) of a Company

You must provide details of each individual who (directly or indirectly):

owns more than 25% of the Issued Capital of a Company Controls the Company.

If neither of these applies, we must collect details of the individual who holds the power to appoint or remove the Trustee of the Trust (‘Appointer’).

ID will be in accordance with the individual verification requirements above.

Power of Attorney

Applications submitted under a power of attorney must be accompanied by an original certified copy of the power of attorney document and a specimen signature of the relevant attorney(s).

Trust or Superfund/SMSF Entity Application
Information you will need to complete the Application Form:

A copy of the trust deed (including any variations to the trust deed) confirming:

the full name of the trust;
the type of trust;
the country where the trust was established; and
the name of each beneficiary or class of beneficiary.
the ABN/ACN.
TFN details or reasons for exemption.
the registered office address.
Trustee Information (Individual or Corporate)
Directors and Beneficial Owners Information (if a Corporate Trustee) the principal place of business of the company.
Personal Information about Directors and Beneficiaries.
Trust/SMSF Bank Account Information
Australia's Anti-Money Laundering and Counter-Terrorism Financing (“AML/CTF”) legislation oblige us to collect Identification Information from prospective Investors (this includes beneficial owners). The online ID Facility, World-Check One, provides the opportunity to complete the identity verification electronically. For further information on World-check One, please visit the World-check One website.

If your investment is below $500,000.00, the applicant must provide a Wholesale Investor Certificate issued by a qualified accountant. For additional information, please visit ASIC’s website.

Beneficial Owner(s) of a: Trust or SMSF

You must provide details of each individual who (directly or indirectly):

owns more than 25% of the Trust / SMSF; or Controls the Trust / SMSF.

If neither of these applies, we must collect details of the individual who holds the power to appoint or remove the Trustee of the Trust (‘Appointer’).

ID will be in accordance with the individual verification requirements above.

Power of Attorney

Applications submitted under a power of attorney must be accompanied by an original certified copy of the power of attorney document and a specimen signature of the relevant attorney(s).

ACCEPT THE TERMS AND CONDITIONS

By ticking each of the boxes below, you acknowledge and agree that:

You have read a copy of the offer document in relation to this fund, e.g. the Information Memorandum or Supplementary Information Memorandum. The offer document is an important document and is required by law. We strongly encourage you to read the offer document to help you decide if the investment meets your needs. *

You give consent to use your personal information for Anti-Money Laundering / Know Your Customer(AML/KYC) verification purposes. *

This application form may be accepted, executed or agreed to through the use of an electronic signature in accordance with the Electronic Transactions (Victoria) Act 2000 and the Electronic Transactions Act 1999 (Cth) and will be binding as if it were physically executed. *

Application Form

Agio Global Investment Fund

This Application Form is in relation to the Information Memorandum dated 1 October 2020 (IM) issued by Lanterne Fund Services Pty Ltd ABN 49 098 472 587, AFSL 238198) (Issuer) in its capacity as trustee of the AGIO Global Investment Fund (Fund).

Agio Global Pty Ltd ACN 640 636 193 is appointed by Lanterne Fund Services Pty Ltd as the investment manager for the Fund and is appointed as a corporate authorised representative of Lanterne Fund Services Pty Ltd.

Agio Global Pty Ltd has appointed Lanterne Fund Services Pty Ltd as an intermediary pursuant to section 911 A (2) (c) of the Corporations Act 2001 (Cth) under which Lanterne Fund Services Pty Ltd is authorised to arrange for the offer to issue, vary or dispose of Units, and by which Agio Global Pty Ltd may issue, vary or dispose of the Units in accordance with those offers that are made, provided those offers are accepted.

It is important that you read the IM in full and the acknowledgments contained in this Application Form before applying for Units.

Unless otherwise defined, capitalised terms used in this Application Form have the same meaning given to them in the IM.

Important: Applications must only be in the name of a natural person or persons, companies or other entities acceptable to the Trustee. If applying under a Trust structure, all account designations must be in the form (Trustee) ATF (Trust).

Questions: If you have other questions relating to this Application Form, please contact us at info@agio.global or+61 (0) 436 661 214.

APPLICATION AMOUNT

I/We apply for *Minimum of $1,000,000

SECTION 1: INVESTOR DETAILS

Please complete this section in conjunction with the AML/CTF Checklist. If the AML/CTF information requirements are not satisfied, then your application will not be accepted.

A. INDIVIDUAL INVESTOR PERSONAL DETAILS

Title *

First Name *

Middle Name

Last Name *

Date of Birth *

Tax File Number or reason for exemption

Residential address (Not PO Box) *

Street addressStreet address line 2

City

State

Postcode

Country

Country of residence for tax purposes (if not Australia)If you are not an Australian resident for tax purposes, please indicate your country of residence for tax purposes.

Phone (Work)

Phone (Home)

Mobile *

A. JOINT HOLDING DETAILS

INVESTOR 1 - PERSONAL DETAILS

Title *

First Name *

Middle Name

Last Name *

Date of Birth *

Tax File Number or reason for exemption

Residential address (Not PO Box) *

Street addressStreet address line 2

City

State

Postcode

Country

Country of residence for tax purposes (if not Australia)If you are not an Australian resident for tax purposes, please indicate your country of residence for tax purposes.

Phone (Work)

Phone (Home)

Mobile *

INVESTOR 2 - PERSONAL DETAILS

Title *

First Name *

Middle Name

Last Name *

Date of Birth *

Tax File Number or reason for exemption

Residential address (Not PO Box) *

Street addressStreet address line 2

City

State

Postcode

Country

Country of residence for tax purposes (if not Australia)If you are not an Australian resident for tax purposes, please indicate your country of residence for tax purposes.

Phone (Work)

Phone (Home)

Mobile *

A. SOLE TRADER PERSONAL DETAILS

Title *

First Name *

Middle Name

Last Name *

Date of Birth *

Tax File Number or reason for exemption

Australian Business Number (ABN)

Residential address (Not PO Box) *

Street addressStreet address line 2

City

State

Postcode

Country

Country of residence for tax purposes (if not Australia)If you are not an Australian resident for tax purposes, please indicate your country of residence for tax purposes.

Business Name (for Sole Trader)

Phone (Work)

Phone (Home)

Mobile *

B. COMPANY / CORPORATE TRUSTEE DETAILS

Full Name of Company or Corporate Trustee *

Tax file number or reason for exemption

ACN or ABN *

Business name (if applicable)

Registered office address (not PO Box)*

Street addressStreet address line 2

City

State

Postcode

Country

Principal Place of Business (not PO Box)*

Street addressStreet address line 2

City

State

Postcode

Country

* For registered foreign companies, this may be the name (care of) and address of the Company’s local agent (if any).

Is this a

Public Companya majority owned subsidiary of a public company ora private company

If this entity is a public company, please provide details of the exchange on which it is listed:

If this entity is a majority owned subsidiary of a public company, please provide the following details:

Name of the parent company:

Details of the exchange on which the parent company is listed:

If this entity is a private company you must also provide details of the directors and beneficial owners.

DIRECTORS PERSONAL DETAILS

Number of Directors *

Director 1 - Title *

First Name *

Middle Name

Last Name *

Director 1 - Residential address *

Street addressStreet address line 2

City

State

Postcode

Country

Director 2 - Title *

First Name *

Middle Name

Last Name *

Director 2 - Residential address *

Street addressStreet address line 2

City

State

Postcode

Country

Director 3 - Title *

First Name *

Middle Name

Last Name *

Director 3 - Residential address *

Street addressStreet address line 2

City

State

Postcode

Country

Director 4 - Title *

Given Name *

Middle Name

Last Name *

Director 4 - Residential address *

Street addressStreet address line 2

City

State

Postcode

Country

If there are more than four directors, please provide details to MSC Abacus via email at registry@msc.group and quote application details.

BENEFICIAL OWNERS PERSONAL DETAILS

Please provide details of all individuals who are beneficial owners through one or more shareholdings of more than 25% of the issued capital of the company.

Number of Beneficiaries *

Beneficial Owner 1 - Title *

Given Name *

Surname *

Date of Birth *

Beneficial Owner 1 - Residential address *

Street addressStreet address line 2

City

State

Postcode

Country

Beneficial Owner 2 - Title *

Given Name *

Surname *

Date of Birth *

Beneficial Owner 2 - Residential address *

Street addressStreet address line 2

City

State

Postcode

Country

Beneficial Owner 3 - Title *

Given Name *

Surname *

Date of Birth *

Beneficial Owner 3 - Residential address *

Street addressStreet address line 2

City

State

Postcode

Country

Beneficial Owner 4 - Title *

Given Name *

Surname *

Date of Birth *

Beneficial Owner 4 - Residential address *

Street addressStreet address line 2

City

State

Postcode

Country

If there are more than four beneficiaries, please provide details to MSC Abacus via email at registry@msc.group and quote application details.

C. PARTNERSHIPS DETAILS

Full Name of Partnership *

Business Name (if applicable)

Tax file number or reason for exemption

Country of Establishment

Registered Office address (not PO Box)*

Street addressStreet address line 2

City

State

Postcode

Country

PARTNER 1 - PERSONAL DETAILS

Title *

Given Name *

Surname *

Date of Birth *

Residential address (not PO Box)*

Street addressStreet address line 2

City

State

Postcode

Country

Tax file number or reason for exemption

Country of residence for tax purposes (if not Australia)

Phone (Work)

Phone (Home)

Mobile *

PARTNER 2 - PERSONAL DETAILS

Title *

Given Name *

Surname *

Date of Birth *

Residential address (not PO Box)*

Street addressStreet address line 2

City

State

Postcode

Country

Tax file number or reason for exemption

Country of residence for tax purposes (if not Australia)

Phone (Work)

Phone (Home)

Mobile *

REGULATION INFORMATION

Is the Partnership regulated by a Professional Body? *

Yes. Provide the following detailsNo

Association name

Association website

Partner’s membership number / reference

D. TRUST / SUPERANNUATION FUNDS DETAILS

Please select the structure of your Trust/Superfund *

Individual Trustee/(s)Corporate Trustee

No. of Individual Trustee/(s)

Full name of Company or Corporate Trustee *

Registered office address

Street addressStreet address line 2

City

State

Postcode

Country

Individual Trustee 1 (Full Name):

Individual Trustee 1 (Address)

Street addressStreet address line 2

City

State

Postcode

Country

Individual Trustee 2 (Full Name):

Individual Trustee 2 (Address)

Street addressStreet address line 2

City

State

Postcode

Country

Individual Trustee 3 (Full Name):

Individual Trustee 3 (Address)

Street addressStreet address line 2

City

State

Postcode

Country

Individual Trustee 4 (Full Name):

Individual Trustee 4 (Address)

Street addressStreet address line 2

City

State

Postcode

Country

Full name of Trust / Superannuation fund *

Tax file Number or Reason for Exemption

Country where Trust / Superannuation was established

REGULATED TRUST

If the Investment is via a Regulated Trust or SMSF, select and complete one of the following 3 options and then go to section E - Politically Exposed Persons.

Self-Managed Superannuation Fund

ABN

Registered Managed Investment Scheme

ARSN

Other Regulated Trust Name of Regulator

Please provide Name of Regulator and Registration/Licensing details

UNREGULATED TRUST

If the Investment is via an Unregulated Trust, select the Type of Unregulated Trust and provide Beneficiary details, Settlors details and Beneficial Owner details.

Please specify

BENEFICIARY DETAILS

Do the terms of the trust identify the beneficiaries by reference to membership of a class?

Yes. Provide details of membership classes (unitholders, family members of named person, charitable organisations).No. Please complete the following:

Number of Beneficiaries

Beneficiary 1 - Title

First Name

Middle Name

Last Name

Beneficiary 2 - Title

First Name

Middle Name

Last Name

Beneficiary 3 - Title

First Name

Middle Name

Last Name

Beneficiary 4 - Title

First Name

Middle Name

Last Name

If there are more than four beneficiaries, please provide details to MSC Abacus via email at registry@msc.group and quote application details.

SETTLOR DETAILS FOR UNREGULATED TRUST

This is only required if the amount used to establish the trust was greater than $10,000 unless the Settlor is deceased.

The full name of the Settlor

BENEFICIAL OWNER(S) / CONTROLLER OF THE TRUST

Please prove details of each individual who (directly or indirectly):

Owns more than 25% of the trust; orControls the trust.

If neither of these applies, then any individual who holds the power to appoint or remove the trustee of the trust (‘Appointer’).

Number of Beneficial Owners

Beneficial Owner 1 - Title

Given Name

Surname

Date of Birth

Beneficial Owner 1 - Residential address *

Street addressStreet address line 2

City

State

Postcode

Country

Beneficial Owner 2 - Title

Given Name

Surname

Date of Birth

Beneficial Owner 2 - Residential address *

Street addressStreet address line 2

City

State

Postcode

Country

Beneficial Owner 3 - Title

Given Name

Surname

Date of Birth

Beneficial Owner 3 - Residential address *

Street addressStreet address line 2

City

State

Postcode

Country

Beneficial owner 4 -Title

Given Name

Surname

Date of Birth

Beneficial Owner 4 - Residential address *

Street addressStreet address line 2

City

State

Postcode

Country

If there are more than four beneficial owners, please provide details to MSC Abacus via email at registry@msc.group and quote application details.

E. POLITICALLY EXPOSED PERSON (‘PEP’)

A “Politically Exposed Person” (PEP) is an individual who holds a prominent public position or function in a government body or international organisation, both within and outside Australia. This definition also extends to their immediate family members or close associates.

Is the Applicant a Politically Exposed Person? *

NoYes

Please provide the name of anyone that is named in this Application Form as a PEP or is an immediate family member or close associate of a PEP.

SECTION 2: APPLICANT’S TAX RESIDENCY AND CLASSIFICATION - FATCA AND CRS

This certification must be completed by all investors to declare their FATCA and CRS status. Please refer to explanations of FATCA terms before completing this form. The Trustee is unable to provide you with tax or professional advice in respect of FATCA or CRS, and we strongly encourage you to seek the advice of an experienced tax or professional adviser in relation to completing this form.

What are FATCA & CRS?

The U.S. Foreign Account Tax Compliance Act (FATCA) and the Common Reporting Standard (CRS) are two ways in which a large number of governments are seeking the same thing – to improve global tax compliance. Both require financial institutions to capture relevant information on foreign taxpayers, as follows:

FATCA promotes cross-border tax compliance by U.S. taxpayers by implementing an international standard for the automatic exchange of information related to those taxpayers. Australia has entered into an inter-governmental agreement (IGA) with the U.S. to implement FATCA in Australia, to be administered through the ATO. The AUS-USA FATCA IGA requires the ATO to obtain detailed account information for U.S. citizens and/or taxpayers on an annual basis. The effect of this is that to satisfy their FATCA obligations, relevant Australian financial institutions must identify any U.S. taxpayers and report those taxpayers’ financial account data to the ATO.
CRS is a global reporting standard developed by the OECD for the automatic exchange of information (AEoI). Its goal is to allow tax authorities to obtain a clearer understanding of financial assets held abroad by their residents for tax purposes. Over 88 countries (refer to OECD link in section IV for participating jurisdictions) have agreed to share information on residents’ assets and incomes in accordance with defined reporting standards. Once again, this means that financial institutions around the globe must provide tax authorities with taxpayer financial account data, and the financial institutions must therefore collect this information from their customers and pass it on.

If you are unable to complete Section 2, please seek appropriate advice relating to the tax information required. For further details relating to the implementation of FATCA and CRS, please refer to the Australian Taxation Office (ATO) website.

A. TAX RESIDENCE – INDIVIDUAL

A. TAX RESIDENCE – SOLE TRADER

Please provide details for all jurisdictions in which the Applicant is resident for tax purposes.

Are you a Tax Resident (outside Australia) *

YesNo

If so, how many? *

Country of Tax Residence 1 *

Taxpayer Identification Number (TIN) 1

Country of Tax Residence 2 (if applicable) *

Taxpayer Identification Number (TIN) 2 (if applicable)

Country of Tax Residence 3 (if applicable) *

Taxpayer Identification Number (TIN) 3 (if applicable)

I certify the tax residence countries provided represent all countries in which I am considered a tax resident.
If Applicant has more than three countries of tax residence please attach a statement to this form containing Applicant, the Country and TIN for each such additional country.

Are you a U.S. citizen or U.S. resident for tax purposes?

A US person includes a US citizen or resident alien of the US even if residing outside the US

Yes. If ‘Yes’, the Applicant’s US country of residence and US Tax Identification Number must be provided above.No. Go to Section 3.

A. TAX RESIDENCE – JOINT HOLDING

Are you a Tax Resident (outside Australia) *

YesNo

If so, how many? *

INVESTOR 1

Please provide details for all jurisdictions in which the Applicant is resident for tax purposes.

Country of Tax Residence 1 *

Taxpayer Identification Number (TIN) 1

Country of Tax Residence 2 (if applicable) *

Taxpayer Identification Number (TIN) 2* (if applicable)

Country of Tax Residence 3 (if applicable) *

Taxpayer Identification Number (TIN) 3* (if applicable)

Are you a U.S. citizen or U.S. resident for tax purposes?

A US person includes a US citizen or resident alien of the US even if residing outside the US

Yes. If ‘Yes’, the Applicant’s US country of residence and US Tax Identification Number must be provided above.No. Go to Section 3.

INVESTOR 2

Are you a Tax Resident (outside Australia) *

YesNo

If so, how many? *

Country of Tax Residence 1 *

Taxpayer Identification Number (TIN) 1*

Country of Tax Residence 2 (if applicable) *

Taxpayer Identification Number (TIN) 2* (if applicable)

Country of Tax Residence 3 (if applicable) *

Taxpayer Identification Number (TIN) 3* (if applicable)

Are you a U.S. citizen or U.S. resident for tax purposes?

A US person includes a US citizen or resident alien of the US even if residing outside the US

Yes. If ‘Yes’, the Applicant’s US country of residence and US Tax Identification Number must be provided above.No. Go to Section 3.

* TIN is the number assigned by each country, for the purpose of administering tax laws (equivalent of a Tax File Number in Australia).

B. COMPANIES, TRUSTS, PARTNERSHIPS AND OTHER ENTITIES

Are you a Tax Resident (outside Australia) *

YesNo

If so, how many? *

I. TAX RESIDENCE – COMPANIES, TRUSTS AND OTHER ENTITIES

Please provide details for all jurisdictions in which the Applicant is resident for tax purposes.

Country of Tax Residence 1 *

Taxpayer Identification Number (TIN) 1*

Country of Tax Residence 2 (if applicable) *

Taxpayer Identification Number (TIN) 2* (if applicable)

Country of Tax Residence 3 (if applicable) *

Taxpayer Identification Number (TIN) 3* (if applicable)

I certify the tax residence countries provided represent all countries in which I am considered a tax resident.

If Applicant has more than three countries of tax residence, please provide details below.

II. FATCA STATUS – COMPANIES, PARTNERSHIPS, TRUSTS AND OTHER ENTITIES

US Person Certification

Is the Applicant a specified US person?

Yes, Provide a US TIN below.If No, complete the section below - Non-US Person Certification.

US Taxpayer Identification Number (‘TIN’):

Non-US Person Certification

APPLICANT’S GLOBAL INTERMEDIARY IDENTIFICATION NUMBER (‘GIIN’) (IF ANY) – COMPANIES, TRUSTS AND OTHER ENTITIESApplicant’s GIIN (if any)

* TIN is the number assigned by each country, for the purpose of administering tax laws (equivalent of a Tax File Number in Australia).

IS THE APPLICANT A FINANCIAL INSTITUTION?

Financial Institution

Is the Applicant an Investment Entity located in a non-CRS Participating Jurisdiction managed by another Financial Institution?

Yes, If yes, please complete the section – Controlling Persons.No, If no, please complete the section below.

Describe the CRS Status

CONTROLLING PERSONS

This section is considered an integral part of the self-certification to which it is associated. If there is a change in Controlling Persons / Beneficial Ownership, please submit an updated form within 30 days.

Number of Controlling Persons

Controlling Person 1 - Title

Given Name

Surname

Are you a Tax Resident (outside Australia) *

YesNo

If so, how many? *

Country of Tax Residence 1

Taxpayer Identification Number (TIN) 1*

Country of Tax Residence 2 (if applicable)

Taxpayer Identification Number (TIN) 2* (if applicable)

Country of Tax Residence 3 (if applicable)

Taxpayer Identification Number (TIN) 3* (if applicable)

Controlling Person 2 - Title

Given Name

Surname

Are you a Tax Resident (outside Australia) *

YesNo

If so, how many? *

Country of Tax Residence 1

Taxpayer Identification Number (TIN) 1*

Country of Tax Residence 2

Taxpayer Identification Number (TIN) 2* (if applicable)

Country of Tax Residence 3

Taxpayer Identification Number (TIN) 3* (if applicable)

If there are more than 2 Controlling Persons or Beneficial Owners or Countries of Tax Residence, please provide the details below.

SECTION 3: DISTRIBUTION PAYMENT DETAILS

Please make deposits to the following account:

Bank Name: *

Account Name: *

BSB Number: *

Account Number: *

Important: For us to process your application, please tick either option 1 or option 2

Option 1 - Important: Please provide a copy or an extract of your bank statement reflecting your Name, BSB and Account number so that we can verify the details against the application form.Option 2 - I / We opt for a call back verification

Important: Please provide a copy or an extract of your bank statement reflecting your Name , BSB and Account number so we can verify the details provided. *

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Please provide a suitable time and contact phone number, and we will give you a call to verify the details.

SECTION 4: METHOD OF PAYMENT

AMOUNT

ELECTRONIC FUNDS TRANSFER OR DIRECT DEPOSIT DETAILS

Ban k Name:	National Australia Bank
Bank Address:	27 Scarborough St Southport QLD 4215
Account Name:	AGIO Global Investment Fund – Applications Account
BSB Number:	084-917
Account Number:	58 556 7917

Important

When depositing funds, please include a reference to: ‘ YOUR NAME OR INVESTING ENTITY’ to enable us to identify the funds. Please ensure the amount you pay is net of any taxes or bank fees which may be levied by your bank in connection with your application.

SECTION 5: REPORTING

Primary Email *Please indicate your preferred email address to receive communications about your Investment.

Full Name *Primary Contact

Contact Phone Number *Primary Contact

Secondary EmailSecondary Contact Email

Full NameSecondary Contact

Contact Phone NumberSecondary Contact

Accountant Details

Accountant/Financial Contact Name

Accountant/Financial Contact Email

If you would like copies of the correspondence emailed to your Financial Adviser, and if you authorise your Financial Adviser to access your investmentinformation (in respect of all your investments) on the Investor Portal, please have your Financial Adviser complete the section on the next page.

SECTION 6: ADVISER USE ONLY

Dealer Group:

Dealer Group AFSL:

Adviser Firm:

Adviser Firm AFSL:

Adviser Name:

Authorized Representative Number:

Adviser Email Address:

Adviser Contact Phone Number:

Please nominate below whether your client’s identification documentation is attached in the Application Form.

Not attached

By ticking this box, I declare that I have completed the AML/CTF identification and verification for this applicant as required by the AML/CTF Actand AML/CTF Rules and I am satisfied that the identity of the applicant is as stated on this Application Form. I have retained a copy of theidentification documents obtained and a record of the procedure undertaken to verify the identity of the applicant and I agree to provide a copy ofthis information upon request to support this declaration.

Attached

Certified copies of the identification documentation specified in the AML section under the relevant investor type are provided with this ApplicationForm.

Please upload identification documents.

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Adviser Signature

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DECLARATION AND SIGNING

By completing, signing, and lodging this Application Form, you acknowledge and agree that:

You have read in full and understood the IM to which this Application Form relates.
The details you have inserted into the Application Form are complete and accurate.
You will be bound by the Trust Deed and the terms on which the Units are being issued (as explained in the IM).
If you are sole signatory signing on behalf of a company, you confirm that you are signing as sole director and sole secretary of the company or as duly authorised representative or agent of the company.
If you are investing as a trustee, on behalf of a superannuation fund or a trust, you confirm that you are acting in accordance with your designated powers and authority under the trust deed. In the case of a superannuation fund, you also confirm that it is a complying fund under the Superannuation Industry (Supervision) Act.
You may not be allocated any Units, and the Trustee has absolute discretion to allocate Units as it sees fit.
You have had the opportunity to seek independent professional advice regarding the legal, taxation and financial implications of investing in the Units and in the Fund generally.
You have not relied on any statements or representations made by anybody (including the AFS Licensee, the Trustee or their officers, employees or agents) prior to applying, other than those representations made in this IM.
If you sign this Application Form under a power of attorney, then a certified copy of the power of attorney is submitted with this Application Form, which as at the date of this application, has not been revoked.
Other than as disclosed in the Application Form, no person or entity controlling, owning, or otherwise holding an interest in the Fund is a United States citizen or resident of the United States for taxation purposes.
You consent to the Trustee disclosing any information it has in compliance with its obligations under the US Foreign Account Tax Compliance Act (‘FATCA’) and the OECD Common Reporting Standards for Automatic Exchange of Financial Account Information (‘CRS’) and any related Australian law and guidance implementing the same. This may include disclosing information to the Australian Taxation Office, who may in turn report that information to the relevant tax authorities as required.

You acknowledge that the collection of your personal information may be required by the Financial Transaction Reports Act 1988, the Corporations Act 2001, the Income Tax Assessment Act 1936, the Income Tax Assessment Act 1997, the Taxation Administration Act 1953, the FATCA and CRS (includes any related Australian law and guidance) and the Anti-Money Laundering and Counter-Terrorism Financing Act 2006. Otherwise, the collection of information is not required by law, but you acknowledge that if you do not provide personal information, the Trustee may not allow you to invest in the Fund.
You are not aware and have no reason to suspect that the monies used to fund your investment in the Fund have been or will be derived from or related to any money laundering, terrorism financing or similar or other activities illegal under applicable laws or regulations or otherwise prohibited under any international convention or agreement (AML/CTF Law).
You will provide the Trustee with all additional information and assistance that the Trustee may request in order for the Issuer to comply with the AML/CTF Law, FATCA and CRS.
You are over the age of 18.
You have made an offer for Units in the Fund and that offer cannot be revoked.
We may accept or reject this application in whole or in part.
Monies invested in the Fund do not represent an investment in or a deposit of or other liability of the AFS Licensee or the Trustee and an investment is subject to investment risk, including possible delays in the repayment and loss of income and capital investment.
You will promptly notify the Trustee of any change to the information you have previously provided to the Trustee, including any changes which result in a person or entity controlling, owning, or otherwise holding an interest in the Fund.
You have provided all documentation requested for AML/CTF investor identification purposes (see page 16)
If your investment is via a trust that is not a registered managed investment scheme, or a government superannuation fund and you have not provided details of the name of each beneficiary or class of beneficiary, you certify that the trust is an unregistered managed investment scheme that only has wholesale clients as beneficiaries and does not make small scale offerings under section 1012E of the Corporations Act.
If an adviser’s details are provided on this form, the Trustee is authorised to provide information directly to that adviser.

PLEASE NOTE

This Application Form must not be handed out or used unless accompanied by the IM. If received through electronic means, you declare you received the Application Form accompanied by or attached to a printout or paper copy of this IM. Units will only be issued on receipt of an Application Form issued together with the IM.

Name of Applicant #1

Date

Signature Applicant #1 *

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Position of applicant (if applicable)

Applicant 1Sole Director & Company Secretary

Position of applicant (if applicable)

DirectorTrusteeAuthorised Signatory

Name of Applicant #2

Date

Signature Applicant #2

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(if joint applicants, then both applicants must sign)

Position of applicant (if applicable)

Applicant 2

Position of applicant (if applicable)

DirectorCompany SecretaryTrustee

Qualified Accountant's Certificate

For investments less than $500,000.00, Section 708 of the Corporations Act specifies that a qualified accountant will be required to certify that the investing entity can be classified as a Wholesale Investor. Please download the following document and forward it to your accountant for completion. Once complete, please upload the signed copy below.

Download Qualified Accountant's Certificate

Qualified Accountant's Certificate Upload

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Qualified Accountant's Certificate

I.D. Verification

To comply with Australia’s Anti-Money Laundering and Counter-Terrorism Financing (AML/CTF) legislation, we must collect certain information from prospective investors and their Beneficial Owners supported by either original certified copies of relevant identification documents or reliable and independent electronic data.

By selecting ‘I/We consent’ below and agree to MSC Abacus performing an online identity verification check using the supplied information. The supplied information will be used to confirm your identity with the Australian Government. Your ID document details will be submitted to the Australian Government's Document Verification Service (DVS). The DVS is a national online system that allows organisations to compare an individual’s identifying information with a government record. More information about the DVS is available on their website.

By providing your consent, you agree that:

You are authorised to provide the ID document of the applicant; and
You understand that the ID document details will be checked against records held by the Issuer or Official Record Holder (including the supplied information and any documents to be verified with the document issuer or official record holder through the DVS).

I/We consent *

Document Upload

Individual/Sole Trader

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Please upload a certified copy of your current passport issued by the Australian or Foreign government.

Individual/Sole Trader

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Please upload a certified copy of your current Driver's Licence issued by the Australian or Foreign government.

Joint Applicant/Partnership - Applicant 1

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Please upload a certified copy of your current passport issued by the Australian or Foreign government.

Joint Applicant/Partnership - Applicant 1

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Please upload a certified copy of your current Driver's Licence issued by the Australian or Foreign government.

Joint Applicant/Partnership - Applicant 2

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Please upload a certified copy of your current passport issued by the Australian or Foreign government.

Joint Applicant/partnership - Applicant 2

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Please upload a certified copy of your current Driver's Licence issued by the Australian or Foreign government.

Partnership Applicant - Partnership Agreement

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Please upload a certified copy or relevant extracts of the partnership agreement, the full name of the partnership and any business name(s) used by the partnership.

Trusts and Superannuation Fund - Trustee 1

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Please upload a certified copy of your current passport issued by the Australian or Foreign government.

Trusts and Superannuation Fund - Trustee 1

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Please upload a certified copy of your current Driver's Licence issued by the Australian or Foreign government.

Trusts and Superannuation Fund - Trustee 2

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Please upload a certified copy of your current passport issued by the Australian or Foreign government.

Trusts and Superannuation Fund - Trustee 2

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Please upload a certified copy of your current Driver's Licence issued by the Australian or Foreign government.

Trusts/Superannuation Fund - Trust Deed (if applicable)

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Please upload a certified copy of the trust deed (including any variations to the trust deed) confirming the full name of the trust, the type of trust, the country where the trust was established, and the name of each beneficiary or class of beneficiary.

Beneficial Owner 1

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Please upload a certified copy of your current passport issued by the Australian or Foreign government.

Beneficial Owner 1

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Please upload a certified copy of your current Driver's Licence issued by the Australian or Foreign government.

Beneficial Owner 2

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Please upload a certified copy of your current passport issued by the Australian or Foreign government.

Beneficial Owner 2

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Please upload a certified copy of your current Driver's Licence issued by the Australian or Foreign government.

Power of Attorney

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Applications submitted under a power of attorney must be accompanied by an original certified copy of the power of attorney document and a specimen signature of the relevant attorney(s).

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