Texas Application Form For Certification As A Certified Capital Company Page 3
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4TEXAS APPLICATION FOR
AP-213-3
(Rev.1-07/2)
CERTIFICATION AS A
CERTIFIED CAPITAL COMPANY
Page 3
1. Name of Proposed Certified Capital Company (“CAPCO”)
7a. Will the CAPCO manage its own affairs? ...............................................................................................................................
YES
NO
7b. Will the CAPCO be managed by
parent
affilliate company
unaffiliated company?
Managing entity
Address
Contact Person
Phone (Area code and number)
FAX (Area code and number)
Email address
7c. Identify the officers or responsible individuals of the Manager/Management Firm that will manage the CAPCO with respect to the Texas CAPCO
Program.
(i)
(ii)
(iii)
(iv)
THE CAPCO MANAGER OR MANAGEMENT FIRM MUST BE LOCATED IN TEXAS. Furnish a CAPCO Biographical Affidavit (Form 25-115) for
each person identified. Submit a copy of the executed management agreement. Prompt written notification must be given if any changes are
made in the managing arrangement and/or the active management.
8. Board of Directors
In the case of a limited liability company, partnership or trust, provide the names of the members of the comparable governing body. The Board of
Directors of a corporation should have at least three (3) members. Furnish a CAPCO Biographical Affidavit (Form 25-115) for each person listed.
Identify each person listed that is a member of any Investment/Loan Committee with an asterisk. Prompt written notification must be given if any
changes are made in the directorate or other comparable governing body.
(a)
(b)
(c)
(d)
9. Names and officers of the CAPCO
In the case of a limited liability company, partnership or trust, provide the names of the comparable responsible individuals. Furnish a CAPCO
Biographical Affidavit (Form 25-115) for each. Prompt written notification must be given if any changes are made in the active management.
President
Secretary
Treasurer
Vice President
Vice President
10. Names of Principals or Manager with Venture Capital Experience
List and identify the principals and/or manager having at least four (4) years experience in venture capital or a venture capital-related industry
who will oversee the CAPCO’s investments. Submit a certified copy of a detailed description of experience for each, including dates, companies,
responsibilities, etc. and furnish a CAPCO Biographical Affidavit (Form 25-115) for each. Prompt written notification must be given if any
changes are made in the active principals or manager with venture capital experience, or of the oversight role that such principals or manager
has or will have.
(a)
(b)
(c)
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