APPLICATION FORM. QCAM UMBRELLA ICAV (an umbrella fund with segregated liability between sub-funds) (the ICAV )

Transcription

1 APPLICATION FORM QCAM UMBRELLA ICAV (an umbrella fund with segregated liability between sub-funds) (the ICAV ) QCAM V-PRO DYNAMIC and QCAM v-pro (each, a Sub-Fund and together, the Sub-Funds ) Please complete this form in blue or black ink using BLOCK CAPITALS. TRADE DATE: day of 20 This application form should be sent without delay to the Administrator at the fax number and address stated below, with the original application form to follow to the address stated below. Redemption proceeds will not be processed until the Administrator is in receipt of the original application form and appropriate anti-money laundering documentation. QCAM Umbrella ICAV c/o CACEIS Ireland Limited (the Administrator ) One Custom House Plaza IFSC Dublin 1 Ireland FB-Reg-Ireland2@CACEIS.COM Fax: The Applicant acknowledges that unless otherwise defined in this application form, all capitalised terms used herein shall have the same meaning as defined terms in the prospectus for the ICAV and the supplements in respect of QCAM v-pro Dynamic or QCAM v-pro dated, as applicable, as each may be amended, supplemented or replaced from time to time (together, the Prospectus ). The Applicant, having received and read a copy of the Prospectus and the Key Investor Information Document(s) ( KIIDs ) for the Sub-Fund(s) and Share Classes to which its investment relates hereby applies to invest in the ICAV, as indicated in the table below: Sub-Fund Name Share Class Currency* QCAM v-pro Dynamic Class A EUR EUR QCAM v-pro Dynamic Class A USD USD QCAM v-pro Dynamic Class A GBP GBP QCAM v-pro Dynamic Class A CHF CHF QCAM v-pro Dynamic Class B EUR EUR QCAM v-pro Dynamic Class B USD USD QCAM v-pro Dynamic Class B GBP GBP QCAM v-pro Dynamic Class B CHF CHF QCAM v-pro Dynamic Class P EUR EUR QCAM v-pro Dynamic Class P USD USD QCAM v-pro Dynamic Class P GBP GBP QCAM v-pro Dynamic Class P CHF CHF QCAM v-pro Class A EUR EUR QCAM v-pro Class A USD USD QCAM v-pro Class A GBP GBP QCAM v-pro Class A CHF CHF QCAM v-pro Class B EUR EUR QCAM v-pro Class B USD USD QCAM v-pro Class B GBP GBP QCAM v-pro Class B CHF CHF QCAM v-pro Class P EUR EUR Amount / Number of Shares (Please delete one) QU085/001/AC#

2 Sub-Fund Name Share Class Currency* QCAM v-pro Class P USD USD QCAM v-pro Class P GBP GBP QCAM v-pro Class P CHF CHF Amount / Number of Shares (Please delete one) *Subscription monies for the Share Classes of a Sub-Fund should be remitted in the designated currency of the relevant Share Class. The Administrator may, at its discretion, accept payment in other currencies, but such payments will be converted into the currency of the relevant Share Class at the then prevailing exchange rate and any conversion expenses shall be borne by the Shareholder. This may result in a delay in processing the application. 2

3 SETTLEMENT DETAILS Currency: Direct via Target II By MT202 (without IBAN) 57A Account with Institution FI BIC: 58A Beneficiary Name & Address: EUR //RT ISAEIE2D ISAEIE2D or By MT103 (with IBAN) 57A Account with Institution FI BIC: //RT ISAEIE2D 59 Beneficiary Name & Address: /IE80 ISAE ISAEIE2D Currency: USD Correspondent Bank: JP Morgan Chase NY Correspondence Swift Code: CHASUS33 CHIPS No: 0002 ABA No: Account No: Beneficiary Account Name: CACEIS Bank Luxembourg Dublin Branch Beneficiary Swift Code: ISAEIE2D Reference: Name of the Sub-Fund name of Applicant Currency: GBP Correspondent Bank: HSBC Bank Plc Correspondent Bank Swift Code: MIDLGB22 Account no: IBAN: GB56 MIDL Beneficiary Account Name: CACEIS Bank Luxembourg Dublin Branch Beneficiary Swift Code: ISAEIE2D Reference: Name of the Sub-Fund name of Applicant Currency: Correspondent Bank: Correspondent Bank Swift Code: Account no: IBAN: Beneficiary Account Name: Beneficiary Swift Code: Reference: CHF UBS, Zurich UBSWCHZH80A X CH X CACEIS Bank Luxembourg Dublin Branch ISAEIE2D Name of the Sub-Fund name of Applicant The Applicant acknowledges that due to applicable anti-money laundering and counter-terrorist financing requirements (the AML Requirements ), the ICAV, the Directors, the Management Company, the Administrator and the Investment Manager may require directly or via a distributor, further identification of the Applicant before the Shares can be registered in the Applicant s name and the ICAV, the Directors, the Management Company, the Administrator and the Investment Manager shall be held harmless and indemnified against any loss arising as a result of a failure to process the application if such information has been required and has not been provided by the Applicant. The Applicant hereby applies for Shares in the Sub-Fund(s) indicated earlier in this application form on the terms and conditions set out in the Instrument of Incorporation of the ICAV, this application form and the Prospectus. The Applicant agrees to be bound by the terms of the Prospectus and the Instrument of Incorporation of the ICAV. 3

4 Where the Applicant is a natural person, he/she confirms that he/she has reached the age of majority under the laws of his/her country of nationality or domicile. Where the Applicant is a corporate entity, it confirms that it has the full right and power to make this application and invest in Shares and all necessary corporate action has been taken to authorise this application and such investment. The Applicant acknowledges that it has received and read the Prospectus and the KIID(s) for the Sub-Fund(s) and Share Class(es) to which its investment relates and that this application is made on the terms of the Prospectus and is subject to the Instrument of Incorporation of the ICAV. The Administrator is hereby authorised and instructed to accept and execute any instruction (including, but not limited to, any instructions regarding subscriptions, switches or redemptions of Shares or any payment in relation to same or otherwise) in respect of Shares, given by the Applicant in written form, by facsimile or by electronic means. The Applicant hereby agrees to indemnify each of the Administrator, the Management Company and the ICAV and to keep each of them indemnified against any loss of any nature whatsoever arising to any of them as a result of any of them acting upon instructions given in written form by the Applicant, i.e., facsimile, confirmed by the Applicant in writing or by electronic means. The Administrator, the Management Company and the ICAV may rely conclusively upon, and shall incur no liability in respect of, any action taken upon any notice, consent, request, instruction or other instrument believed in good faith to be genuine or to be signed by properly authorised persons. Amendments to investors registration details and payment instructions will only be effected on receipt of an original instruction which has been duly authorised. The Applicant is fully empowered and has authority to make this investment whether the investment is on its own behalf or on the behalf of another person or institution. The Applicant hereby represents and warrants that the Shares are not being acquired and will not be held in violation of any applicable laws. The Applicant hereby confirms that cleared funds representing the subscription monies for initial or subsequent applications for Shares transmitted to the relevant account(s) as detailed under Settlement Details above prior to the relevant Dealing Day, or at the end of the Initial Offer Period, as applicable, are not to be held on trust for the Applicant by the ICAV. The Applicant accordingly acknowledges that such monies shall not be subject to the Central Bank (Supervision and Enforcement) Act 2013 (Section 48(1)) Investor Money Regulations 2015 for Fund Service Providers or to any equivalent client asset protection account and that the Applicant may be exposed to the creditworthiness of the relevant credit institution where such subscription monies are held. The Applicant hereby acknowledges and agrees that in such circumstances none of the ICAV, the Management Company, the Administrator or the Depositary shall have any liability or responsibility for any loss of such monies prior to the transfer of such monies to the ICAV s account. The Applicant hereby acknowledges that in accordance with the AML Requirements, redemption monies or dividend payments shall not be paid until the signed application form and all documents required in connection with the obligation to prevent money laundering have been received by the Administrator and all anti-money laundering procedures have been completed satisfactorily. In the event that the Applicant fails to submit the necessary documentation requested by the ICAV or its delegate as required under the AML Requirements, redemption monies or dividend payments will be held in the relevant Sub-Fund s account and shall remain an asset of the relevant Sub-Fund and the Applicant will not benefit from the application of any investor money protection rules (i.e., the redemption monies/dividend payments will not be held on trust for the Applicant). In such circumstances, the Applicant acknowledges that it will be an unsecured creditor of the relevant Sub-Fund in respect of such redemption monies/dividend payments until such time as the relevant documentation required by the ICAV has been received to its satisfaction and the redemption monies/dividend payments have been paid to the Applicant. If insufficient information is provided by the Applicant in order to satisfy the AML Requirements, each of the ICAV, the Management Company, the Administrator and the Investment Manager may take such steps as they deem necessary to discontinue the relationship with the Applicant. In the event that Shares are issued notwithstanding that cleared funds representing the subscription monies for initial or subsequent applications for Shares have not been received by the relevant Settlement Time, the Applicant acknowledges that the ICAV may cancel the issue of the Shares or the Applicant may be charged interest on the outstanding subscription monies at normal commercial rates and, in such an event, the Applicant may be held liable for any loss to the relevant Sub-Fund. The Applicant confirms that it has the right and the authority to request a redemption of Shares and confirms that the Applicant will comply with the redemption procedures set out in the Prospectus. All redemption instructions must be given in writing, quoting the relevant account number and be accompanied by the relevant redemption documentation. The Applicant agrees to immediately sell or to tender to the ICAV for redemption or transfer Shares held by it in the ICAV if the continuing holding of the Shares by it would result in regulatory, pecuniary, legal, taxation or material administrative disadvantage for the ICAV or the Shareholders as a whole or be otherwise contrary to the provisions of the Prospectus. 4

5 The Applicant hereby agrees to indemnify and keep indemnified the ICAV, the Management Company, the Investment Manager, the Administrator and the Depositary, their affiliates, and the officers, directors, employees and professional advisers of any of the foregoing, from and against any loss arising to any of them as a result of any breach of any representation, warranty, covenant, undertaking, agreement, declaration, acknowledgement, instruction or confirmation by the Applicant in this application form or from the Applicant s failure to disclose any relevant details or provide it with all the information requested by the ICAV, the Management Company, the Investment Manager, the Administrator or the Depositary. In the case of delay or failure to provide satisfactory information, each of the ICAV, the Management Company and the Administrator may take such action (including declining to accept an application) as they think fit. (In respect of joint Applicants only). The Applicants direct that on the death of one of them the Shares for which they hereby apply be held in the name of and to the order of the survivor or survivors of the Applicants or the executor or manager of such survivor or survivors. The Applicant undertakes to observe and be bound by the provisions of the Instrument of Incorporation of the ICAV (as amended from time to time) and applies for the Shares issued in relation to this application to be entered in the register of Shareholders in the name of the Applicant (or in the name of a nominee or agent). The Applicant agrees to accept such lesser number of Shares, if any, than may be specified above in respect of which this application may be accepted. The Applicant acknowledges that Shares are subject to investment risks, including possible loss of principal amount invested. The Applicant confirms its agreement with the dividend policy as outlined in the Prospectus. The Applicant understands that the representations and warranties made herein are continuous and all subsequent subscriptions of Shares by the Applicant shall be governed by them, and the Applicant agrees to notify the ICAV, the Management Company or the Administrator promptly if any representation or warranty should cease to be true at any time. The Applicant acknowledges that, once submitted, this application form shall, subject to applicable law and regulation, be irrevocable by, and binding on, the Applicant. The Applicant consents to any notice or other document to be sent by the ICAV, the Management Company or the Administrator to the Applicant as a Shareholder, including, without limitation, the annual and other periodic reports and, the KIID(s), being sent by electronic means including but not limited to , swift or posting such notice or other document on a website notified to the Applicant by post or by . The Applicant confirms that it has been notified electronically of the Management Company s website address and the place on the Management Company s website where the KIID(s) may be accessed. The Applicant acknowledges that it will be entitled to look solely to the assets of the relevant Sub-Fund in respect of all payments in respect of its Shares. If the realised net assets of the relevant Sub-Fund are insufficient to pay any amounts payable in respect of the relevant Shares, the Applicant will have no further right of payment in respect of such Shares nor any claim against or recourse to any of the assets of any other Sub-Fund or any other asset of the ICAV or of the Management Company or of the Administrator or of the Depositary. 5

6 CONFIRMATION OF OWNERSHIP If you wish confirmation of ownership to be sent to you on a monthly basis please tick and ensure that your contact details are inserted below. Yes No Name: Name: Name: Name: DATA PROTECTION The Applicant hereby acknowledges that by completing the application form they have provided personal information, which may constitute personal data within the meaning of the Irish Data Protection Acts 1988 and 2003, the EU Data Protection Directive 95/46/EC, the EU eprivacy Directive 2002/58/EC (as amended) and any relevant transposition of, or successor or replacement to, those laws (including, when they come into force, the General Data Protection Regulation (Regulation (EU) 2016/679) and the successor to the eprivacy Directive) (together, the Data Protection Legislation ). Applicants personal data will be used by the ICAV for the following purposes: to manage and administer the Applicant s holding in the ICAV and any related accounts on an ongoing basis in accordance with the contract between the Applicant and the ICAV; to carry out statistical analysis and market research as the ICAV s legitimate business interest; to comply with legal and regulatory obligations applicable to the Applicant and the ICAV from time to time, including, without limitation, applicable tax, anti-money laundering and counter terrorist financing legislation. In particular, in order to comply with the information reporting regimes set out in Section 891C and Section 891E to Section 891G (inclusive) of the Taxes Consolidation Act 1997 (as amended) and regulations made pursuant to those sections), Applicants personal data (including financial information) may be shared with the Irish Revenue Commissioners. They in turn may exchange information (including personal data and financial information) with foreign tax authorities (including foreign tax authorities located outside the European Economic Area). Please consult the AEOI (Automatic Exchange of Information) webpage on for further information in this regard; to record the telephone calls from Applicants and other individuals to the Company and its agents and service providers for record-keeping, security, quality assurance and training purposes; for any other specific purposes where the Applicant has given specific consent. Applicants personal data may be disclosed by the ICAV to its delegates, professional advisors, service providers, regulatory bodies, auditors, technology providers and any duly authorised agents or related, associated or affiliated companies of the foregoing for the same or related purposes. Applicants personal data may be transferred to countries which may not have the same or equivalent data protection laws as Ireland. If such transfer occurs, the ICAV is required to ensure that such processing of Applicants personal data is in compliance with Data Protection Legislation and, in particular, that appropriate measures are in place such as entering into model contractual clauses (as published by the European Commission) or ensuring that the recipient is Privacy Shield certified, if appropriate. For more information on the means of transfer of Applicants data or a copy of the relevant safeguards, please contact FB-Reg-Ireland2@CACEIS.COM. Pursuant to the Data Protection Legislation, Applicants have a number of rights which may be exercised in respect of their personal data, i.e.: the right of access to personal data held by the ICAV; 6

7 the right to amend and rectify any inaccuracies in personal data held by the ICAV; the right to erase personal data held by the ICAV; the right to data portability of personal data held by the ICAV; and the right to request restriction of the processing of personal data held by the ICAV; and the right to object to processing of personal data by the ICAV. These rights will be exercisable subject to limitations as provided for in the Data Protection Legislation. In certain circumstances it may not be feasible for the ICAV to discharge these rights, for example because of the structure of the ICAV or the manner in which the applicant holds Shares in a Fund. Applicants may make a request to the ICAV to exercise these rights by contacting FB-Reg-Ireland2@CACEIS.COM. Please note that personal data may be retained by the ICAV for the duration of an applicant s investment and afterwards in accordance with the ICAV s legal and regulatory obligations including but not limited to the ICAV s record retention policy. The ICAV is a data controller within the meaning of the Data Protection Legislation and undertakes to hold any personal information provided by applicants in confidence and in accordance with the Data Protection Legislation. For queries, requests or comments in respect of this notice or the way in which the ICAV uses Applicants personal data, please contact FB-Reg-Ireland2@CACEIS.COM. Applicants have the right to lodge a complaint with the Office of the Data Protection Commissioner if they are dissatisfied with the manner in which their personal data is used by the ICAV. From time to time, the Fund Parties (acting on behalf of the ICAV) may send you information about other products and services which they offer and believe may be of interest to you. You have a right not to receive such information. If you do not wish to receive marketing material from any such Fund Party, please tick the box below. If you do not wish to receive such information, please tick here ELECTRONIC DELIVERY OF ACCOUNT INFORMATION The Applicant hereby agrees and consents to have the ICAV, the Management Company, the Investment Manager and/or the Administrator electronically deliver Account Communications (as defined below) to it. Account Communications means all current and future account statements, constitutional documents of the ICAV (including the Prospectus, the Instrument of Incorporation and any supplements and/or amendments thereto), the KIID(s), letters to investors, annual audited financial statements, regulatory communications and other information, documents, data and records regarding the Shareholder s investment in a Sub-Fund. Electronic communication by the ICAV, the Management Company, the Investment Manager and/or the Administrator includes delivery as well as electronically making available Account Communications to Shareholders on the Management Company s or the Investment Manager s internet site, if applicable. The Applicant hereby represents that it has regular access to the internet. The Applicant acknowledges that it has been offered the choice of receiving the KIID(s) on paper and in electronic form by means of a website or by and hereby specifically consents to receiving the KIID(s) in electronic form by way of or by accessing the latest version of the document online at (or such other website address as may be notified to the Applicant from time to time) through the Key Investor Information Document (KIID) tab. The Applicant hereby acknowledges that it has received or accessed by electronic means the KIID(s) in respect of the relevant Share Class or representative Share Class. The Applicant also consents to accessing the KIID(s) by electronic means before making any subsequent and/or future subscriptions for Shares in any Share Class and/or Sub-Fund. Where the Applicant is acquiring the Shares for or on behalf of any person in its capacity as a sub-distributor of the ICAV, the Applicant certifies that prior to accepting any order for the acquisition of Shares, the Applicant will ensure that the investor will be provided with the current KIID(s) for the relevant Share Class. Where permitted by applicable law, 7

8 provided shall include informing the investor of the applicable website where the KIID(s) may be obtained, which is (or such other website address as may be notified to the Applicant from time to time). The Applicant s address is set forth below under the heading Details of Applicant(s). The Applicant hereby agrees to notify the ICAV in writing if its address details change. If an address is not provided, all communications will be delivered via post to the registered address of the Applicant set forth below under the heading Details of Applicant(s). The Applicant hereby acknowledges that it may at any time request a paper copy of the Prospectus or the KIID(s) from the ICAV and that it may revoke or restrict its consent to electronic delivery of Account Communications at any time by notifying the ICAV, in writing, of its intention to do so. The Applicant hereby agrees that the ICAV, the Management Company, the Investment Manager and the Administrator will not be liable for any interception of Account Communications. Shareholders should note that no additional charge for electronic delivery will be assessed, but Shareholders may incur charges from Internet service or access providers. In addition, there are risks, such as systems outages, that are associated with electronic delivery. 8

9 US PERSONS I/We confirm that I am/we are not a US Person (as defined in the Prospectus), am/are not applying for Shares as a nominee of a U.S. Person, and am/are not acting on behalf of, nor do I/we intend to transfer any Shares which I/we may purchase to, any US Person Return of Values (Investment Undertakings) Regulations, 2013 Pursuant to the Return of Values (Investment Undertakings) Regulations, 2013, any Applicant who is an individual, company or any unincorporated body of persons which are an Irish resident or ordinarily Irish resident must provide the following additional information and documentation: Tax Identification Number (TIN) / PPS applicable) Number (if Any one of the following additional documents is required to verify the TIN or PPS Number (either a copy or the original is sufficient): P60, P45, P21 Balancing Statement, payslip (where employer is identified by name or tax number), Drug Payment Scheme Card, European Health Insurance Card, Tax Assessment, Tax Return Form, PAYE Notice of Tax Credits, Child Benefit Award Letter/Book, Pension Book, Social Services Card or Public Services Card. In addition, any printed documentation issued by the Irish Revenue Commissioners or by the Department of Social Protection which contains the Applicant s name, address and tax reference number will also be acceptable. In the case of joint account holders, the additional documentation is required for each Applicant. 9

10 POLITICALLY-EXPOSED PERSONS Please complete EITHER Section A or B below, with reference to the definitions below A Politically-Exposed Person ( PEP ) is an individual who has at any time in the preceding 12 months been entrusted with a prominent public function. This includes the following individuals (but excluding any middle ranking or more junior official): a. a specified official ; and b. a member of the administrative, management or supervisory body of a state-owned enterprise. A specified official is (including any such officials in an institution of the European Communities or an international body): a. a head of state, head of government, government minister or deputy or assistant government minister; b. a member of a parliament; c. a member of a supreme court, constitutional court or other high level judicial body whose decisions, other than in exceptional circumstances, are not subject to further appeal; d. a member of a court of auditors or of the board of a central bank; and e. an ambassador, chargé d affairs or high-ranking officer in the armed forces. An immediate family member of a PEP includes any of the following persons: a. any spouse of the PEP; b. any person who is considered to be equivalent to a spouse of the PEP under the national or other law of the place where the person or PEP resides; c. any child of the PEP; d. any spouse of a child of the PEP; e. any person considered to be equivalent to a spouse of a child of the PEP under the national or other law of the place where the person or child resides; f. any parent of the PEP; and g. any other family member of the PEP who is of a class prescribed by the Minister for Justice under section 37(11) of the Criminal Justice (Money Laundering and Terrorist Financing) Acts, 2010 and A close associate of a PEP includes any of the following persons a. any individual who has joint beneficial ownership of a legal entity or legal arrangement, or any other close business relations, with the PEP; and b. any individual who has sole beneficial ownership of a legal entity or legal arrangement set up for the actual benefit of the PEP. As an example, a beneficial owner of a body corporate is any individual who (other than a company having securities listed on a regulated market): a. ultimately owns or controls, whether through direct or indirect ownership or control (including through bearer shareholdings) more than 25% of the shares or voting rights of the body; or b. otherwise exercises control over the management of the body. SECTION A: TO BE COMPLETED ONLY IF THE PEP RULES APPLY WITH REFERENCE TO THE ABOVE DEFINITIONS: the application is being made by a PEP / immediate family member of a PEP / close associate of a PEP; OR the Applicant has a beneficial owner who is a PEP / immediate family member of a PEP / close associate of a PEP; OR the application is being made for the benefit of a PEP / immediate family member of a PEP / close associate of a PEP; OR it is intended to transfer the Shares to a PEP / immediate family member of a PEP / close associate of a PEP Name of PEP: Address of PEP: Office of PEP: Relationship of Applicant or Applicant s beneficial owner to PEP: Source of Wealth of the Applicant (e.g., income from employment, income from company business, inheritance etc.): SECTION B: PLEASE CHECK BOX BELOW IF THE PEP RULES DO NOT APPLY WITH REFERENCE TO THE ABOVE DEFINITIONS: I/we confirm that the application is NOT being made by a PEP / immediate family member of a PEP / close associate of a PEP; AND the application is NOT being made for the benefit of a PEP / immediate family member of a PEP / close associate of a PEP; AND 10

11 the Applicant does not have a beneficial owner who is a PEP / immediate family member of a PEP / close associate of a PEP; AND it is NOT intended to transfer the Shares to a PEP / immediate family member of a PEP / close associate of a PEP. 11

12 This section is for all applicants DETAILS OF APPLICANT(S) First Applicant: Registered Name: Account Designation (if any): Nature and Purpose of Entity: Registered Address (PO or C/O will not be accepted): Mailing Address (if different): Address: Contact Name: Tel No.: Fax No.: Additional Information for Individuals: Source of wealth (e.g., inheritance, income from employment, income from business activities) (if individual): Occupation (If individual or joint account): Joint Applicant(s): Details of up to 3 additional holders may be added to the application by completing Schedule A attached hereto. 12

13 This section is for bodies corporate only BENEFICIAL OWNER(S) If the Applicant is a body corporate and is beneficially owned by one or more persons, the following information must be provided. A beneficial owner is considered to be an individual or corporate entity: (a) which ultimately owns or controls, whether through direct or indirect ownership or control (including through bearer shareholdings) more than 25% of the share or voting rights of the Applicant, or (b) otherwise exercises control over the management of the Applicant. Beneficial Owner 1 (where applicable): Registered Name: Registered Address (PO or C/O will not be accepted): Entity Type: Date of Birth (if individual): Beneficial Owner 2 (where applicable): Registered Name: Registered Address (PO or C/O will not be accepted): Entity Type: Date of Birth (if individual): Beneficial Owner 3 (where applicable): Registered Name: Registered Address (PO or C/O will not be accepted): Entity Type: Date of Birth (if individual): Beneficial Owner 4 (where applicable): Registered Name: Registered Address (PO or C/O will not be accepted): Entity Type: Date of Birth (if individual): 13

14 APPLICANT BANK ACCOUNT DETAILS FOR REDEMPTION AND/OR DIVIDEND PAYMENTS, WHERE RELEVANT Please list the details of the account to which redemption proceeds and/or dividends should be paid. Payments will only be made to a bank account held in the name of the registered Shareholder. No third party payments will be made. Redemptions will not be processed on non-cleared/verified accounts. Both IBAN and SWIFT (BIC) Codes should be quoted for all banks within the EU/EEA. Amendments to the Applicant s payments instructions will only be effected upon receipt of an original instruction which has been duly authorised. In the case of joint accounts, instructions will only be made upon receipt of instructions duly signed by all Applicants. Correspondent Bank Name : Correspondent Bank Address: Correspondent Bank Sort Code/SWIFT (BIC)/ABA/Fedwire: Beneficiary Bank Name: Beneficiary Bank Address: Beneficiary Bank Sort Code/SWIFT (BIC)/ABA/Fedwire: Beneficiary Account Name: Beneficiary Account Number: Reference: 14

15 DECLARATION OF RESIDENCE OUTSIDE IRELAND (This section must be completed and signed) Applicants resident outside Ireland are required by the Irish Revenue Commissioners to make the following declaration which is in a format authorised by them, in order to receive payment without deduction of tax. It is important that this declaration, if it is then still correct, shall apply in respect of any subsequent acquisitions of Shares. Terms used in the declaration are defined in the Prospectus. Declaration on own behalf (*Please delete as appropriate) I/we* declare that I am/we are* applying for the Shares on my own/our own behalf/on behalf of a company* and that I am/we are/the company* is entitled to the Shares in respect of which this declaration is made and that I am/we are/the company is* not currently Irish Resident or ordinarily resident in Ireland, and should I/we/the company* become Irish Resident or ordinarily resident in Ireland I/we will so inform you, in writing, accordingly. OR Declaration as Intermediary (*Please delete as appropriate) I/we* declare that I am/ we are* applying for Shares on behalf of persons: who are beneficially entitled to the Shares; and who, to the best of my/our* knowledge and belief, are neither Irish Resident nor ordinarily resident Ireland. I/we* also declare that: Unless I/we* specifically notify you to the contrary at the time of the application, all applications for Shares made by me/us* from the date of the application will be made on behalf of such persons; and I/we will inform you in writing, if I/we* become aware that any person, on whose behalf I/we* holds Shares, becomes Irish Resident or ordinarily resident in Ireland. NOTES: Non-resident declarations are subject to inspection by the Irish Revenue Commissioners and it is a criminal offence to make a false declaration. In the case of a firm (not a limited company) applications should be in the name(s) of and signed by the proprietor(s). To be valid, the application form (incorporating the declaration required by the Irish Revenue Commissioners) must be signed by the Applicant. Where there is more than one Applicant, each person must sign. If the application is a company, it must be signed by the company secretary or another authorised officer. If the application form (incorporating the declaration required by the Irish Revenue Commissioners) is signed under power of attorney, a copy of the power of attorney must be furnished in support of the signature. If this form is not fully completed to the satisfaction of the Administrator, the application/transfer may not be accepted. The Administrator acting on behalf of the ICAV reserves the right to reject an application for Shares in whole or in part. Persons who are resident or ordinarily resident in Ireland and who are seeking to apply for Shares should contact the Administrator for an application form, which does not include the above declaration. Irish residents who are entitled to payment without deduction of tax (i.e., exempt Irish Investor) should also request the appropriate alternative declaration form from the Administrator. Applicants who are resident in Ireland but not a taxable Irish person should contact the Administrator for the alternative declaration available for such Applicants. 15

16 AUTHORISATION The Applicant(s) agree(s) to be bound by the declarations, representations, consents and indemnities set out in this application form. Principal Applicant Signature / Authorised Signatory: (Declarant) Capacity of authorised signatory (if applicable): Name (block capitals): Date: day of, 20. Joint Applicants: Name: Signature: Name: Signature: Name: Signature: Name: Signature: 16

17 ANTI-MONEY LAUNDERING REQUIREMENTS Documentation required from Applicants on initial subscription Completed documentation should be sent to the Administrator by fax first ( ) with the original or certified true copies to follow by post immediately thereafter to the Administrator at the address provided. Contact the Administrator if none of the below categories are relevant to the entity investing in a Sub-Fund (e.g., charities, clubs, colleges, direct nominees, investment funds in a non-prescribed country, nominees in a non-prescribed country, partnerships, pensions in a non-prescribed country, public bodies in a non EU country, trusts in a non-prescribed country, societies, universities, etc.). 1 - Individuals 2 - Regulated/listed entities in a prescribed country 3 - Regulated/listed entities in a non-prescribed country or non-regulated companies 4 - Trusts in a prescribed country 5 - Nominee in a prescribed country with a regulated parent company in a prescribed country 6 - Regulated mutual funds/hedge funds/unit trusts in a prescribed country 7 - Registered pension funds/plans/schemes in a prescribed country 8 - Pension trustees or private pension funds/plans/schemes in a prescribed country with a regulated trustee or regulated administrator in a prescribed country List of prescribed/equivalent countries Prescribed countries 1 EU member states 2 Australia Brazil Canada Hong Kong Iceland India Japan Liechenstein Mexico Norway Singapore South Africa South Korea Switzerland The United States of America The Channel Islands and Isle of Man The Dutch overseas territories of Netherlands Aruba, Curacao, Sint Maarten, Bonaire, Sint Eustatious and Saba The French overseas territories of Mayotte, New Caledonia, French Polynesia, Saint Pierre and Miquelon and Wallis and Futuna Non-prescribed countries Any other country not listed above is deemed to be non-equivalent 1 An equivalent country is a country prescribed by the Minister for Justice as being a country with equivalent anti-money laundering and countering financial terrorism policies to Ireland (S.I. No. 347 of 2012 published on 12 September 2012) (please note this list is subject to change). 2 EU member states: Austria, Belgium, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden and the United Kingdom. 17

18 1 - Individuals Certified copy of a current official identification document in date Original or certified copies of two recent address verification documents (less than six months old) Declaration of the source of wealth to declare the exact source of wealth and to provide evidence for the source of wealth Fully completed original application form for the ICAV with bank details Certification In relation to the certification of the documents, copies of the documents must be certified by a suitable person such as: a notary public; a commissioner for oaths; a police officer; an embassy/consular official; a chartered or certified public accountant; a practising solicitor; or a designated body in a prescribed country. A certified document is one that is stamped, signed and dated as being a true copy of the original at a particular date in time. The certification stamp must be present on the document. Personal identification Acceptable personal identification documents are the original or certified copy of a passport, driver's licence or national identity card. The documents must be within expiry date, show a picture of the person, full name, date of birth and signature of the person. Address verification Acceptable address verification documents are the original or certified copies of any two of the following: electricity bill, gas bill, water bill, telephone bill, cable television bill, bank statement or credit card statement, social insurance documents, household/motor insurance certificates and statement from a tax authority. Documents must originate from a different source, show the full name and residential address of the individual and must be dated within six months of submission. Please note that mobile phone bills are not admissible. 2 Regulated company in a prescribed country Original letter of assurance Original or certified copy of the authorised signatory list Fully completed original fund application form for the ICAV with bank details 3 - Regulated/listed entities in a non-prescribed country or non-regulated companies Certificate of incorporation or certificate to trade (certified copy) Certified copy of the certificate of registration Certified copy of the memorandum and articles of association or equivalent Original list of directors' full names, occupations, residential and business addresses and dates of birth A properly authorised mandate of the directors to open/operate the account or establish the business relationship with the ICAV (original or certified copy) Certified copy of the personal identification documents and two address verification documents of at least two directors Certified copy of the personal identification documents and two address verification documents of all authorised signatories Original list and identification documents of all shareholders holding 25% or more of the issued share capital of the company. For funds registered in the Cayman Islands, the threshold is 10%. In the case of individual shareholders, a certified copy of the personal identification documents and two address verification documents. In the case of a company, a certified copy of the certificate of incorporation, memorandum and articles of association, authorised signatory list, list of directors, identification of two directors and of all authorised signatories, authorised mandate of the directors and identification of the shareholders (as above). We are also obliged to identify the ultimate beneficial owners for all shareholders owning 25% or more of the issued share capital (for funds registered in the Cayman Islands, the threshold is 10%) Original or certified copy of the authorised signatory list printed on company headed paper Fully completed original application form for the ICAV with bank details Certified copy of the latest audited annual report 18

19 Certification In relation to the certification of the documents, a copy of the documents must be certified by a suitable person, such as: a notary public; a commissioner for oaths; a police officer; an embassy/consular official; a chartered or certified public accountant; a practising solicitor; or a designated body in a prescribed country. A certified document is one that is stamped, signed and dated as being a true copy of the original at a particular date in time. The certification stamp must be present on the document. Personal identification Acceptable personal identification documents are the original or certified copy of a passport, driver's licence or national identity card. The documents must be within expiry date, show a picture of the person, full name, date of birth and signature of the person. Address verification Acceptable address verification documents are the original or certified copies of any two of the following: electricity bill, gas bill, water bill, telephone bill, cable television bill, bank statement or credit card statement, social insurance documents, household/motor insurance certificates and statement from a tax authority. Documents must originate from a different source, show the full name and residential address of the individual and must be dated within six months of submission. Please note that mobile phone bills are not admissible. 4 - Trusts in a prescribed country Confirmation of name and address (certified copy or copy from online official company registry) Authorised signatory list (original or certified) Fully completed application form for the ICAV including bank details (original) Trust deed and any subsequent supplements to the trust deed (original or certified copy) List of trustees to include full names, occupations, residential and business addresses and dates of birth (original or certified copy) A properly authorised mandate of the trustees to open/operate the account or establish the business relationship (original or certified copy) Personal identification documents and two address verification documents of at least two trustees/directors. In the case of a company, a certified copy of the certificate of incorporation, memorandum and articles of association, authorised signatory list, list of directors, identification of two directors and of all authorised signatories, authorised mandate of the directors and identification of the shareholders (as per section 3). We are also obliged to identify the ultimate beneficial owners for all shareholders owning 25% or more of the issued share capital Personal identification documents and two address verification documents of all authorised signatories List of beneficiaries to include full name, occupations, residential and business addresses and dates of birth (original or certified). Personal identification documents and two address verification documents should also be provided (certified copy). In the case of a company, certified copy of the certificate of incorporation, memorandum and articles of association, authorised signatory list, list of directors, identification of two directors and of all authorised signatories, authorised mandate of the directors and identification of the shareholders (as per section 3). We are also obliged to identify the ultimate beneficial owners for all shareholders owning 25% or more of the issued share capital List of settler/grantor/donor to include full name, occupations, residential and business addresses, dates of birth and source of funds (original or certified copy). Personal identification documents and two address verification documents should also be provided (certified copy) Certification In relation to the certification of the documents, a copy of the documents must be certified by a suitable person, such as: a notary public; a commissioner for oaths; a police officer; an embassy/consular official; a chartered or certified public accountant; a practising solicitor; or a designated body in a prescribed country. A certified document is one that is stamped, signed and dated as being a true copy of the original at a particular date in time. The certification stamp must be present on the document. 19

20 Personal identification Acceptable personal identification documents are the original or certified copy of a passport, driver's licence or national identity card. The documents must be within expiry date, show a picture of the person, full name, date of birth and signature of the person. Address verification Acceptable address verification documents are the original or certified copies of any two of the following: electricity bill, gas bill, water bill, telephone bill, cable television bill, bank statement or credit card statement, social insurance documents, household/motor insurance certificates and statement from a tax authority. Documents must originate from a different source, show the full name and residential address of the individual and must be dated within six months of submission. Please note that mobile phone bills are not admissible. 5 - Nominee in a prescribed country with a regulated parent company in a prescribed country 5.1 Original letter of assurance from the parent company Authorised signatory list for the parent company (certified copy) Application form for the ICAV in the name of the nominee with bank details (original) Authorised signatory list for the nominee (certified copy) 6 Regulated mutual funds/hedge funds/unit trusts in a prescribed country Fund prospectus/offering memorandum (copy) Original application form for the ICAV (fully completed) Certified copy of the authorised signatory list for the fund Original letter of assurance from the entity responsible for the anti-money laundering due diligence on the fund and its investors Certified copy of the authorised signatory list for the company signing the letter of assurance The investment manager and the entity responsible for the anti-money laundering due diligence on the fund and its investors (usually the fund administrator) are required to provide their anti-money laundering due diligence documents only if they are not regulated. Please refer to section 3 ( Regulated/listed entities in a non-prescribed country or non-regulated companies ) 7 Registered pension schemes/plans/schemes in a prescribed country Certified copy of the trust deed/appointment of trustees Certified copy of the confirmation of pension registration Original application form for the ICAV (fully completed) Certified copy of the authorised signatory list 8 Regulated pension trustees or private pension funds/plans/schemes with a regulated trustee or administrator in a prescribed country Certified copy of the trust deed/appointment of trustees Original letter of assurance from the trustee (if regulated) or from the administrator Original application form for the ICAV (fully completed) Certified copy of the authorised signatory list 20

21 ANTI-MONEY LAUNDERING CONFIRMATION FOR NOMINEES/INTERMEDIARIES This confirmation can only be completed by designated bodies regulated for anti-money laundering purposes by the appropriate regulator in an EU member state or in one of the following jurisdictions: Australia; Brazil; Canada; Hong Kong; Iceland; India, Japan, Liechtenstein; Mexico; Norway; Singapore; South Africa; South Korea; Switzerland; the United States of America; the Channel Islands and the Isle of Man; the Dutch overseas territories of Netherlands Aruba, Curacao, Sint Maarten, Bonaire, Sint Eustatius and Saba; or the French overseas territories of Mayotte, New Caledonia, French Polynesia, Saint Pierre and Miquelon and Wallis and Futuna (please note this list is subject to change). DESCRIPTION OF APPLICANT DESIGNATED BODY INVESTING AS AN INTERMEDIARY NOMINEE COMPANY RELATIONSHIP OF CONFIRMATION PROVIDER (REGULATED ENTITY) TO APPLICANT APPLICANT PARENT OF APPLICANT UNLESS THE FOLLOWING BOX IS TICKED THE ADMINISTRATOR WILL APPLY THE BELOW CONFIRMATION TO ANY SUBSEQUENT DESIGNATED ACCOUNTS IN THE NAME OF THIS APPLICANT. DO NOT APPLY THE BELOW CONFIRMATION TO SUBSEQUENT DESIGNATIONS Name of regulated entity Name of regulator Address of regulated entity We confirm that we are a designated body regulated for anti-money laundering purposes by the above regulator and hereby confirm the following in connection with the Applicant: 1. We / the Applicant* has performed the anti-money laundering and counter-terrorist financing identification for any parties on whose behalf of the Applicant is purchasing Shares ( underlying investors ). 2. The evidence we / the Applicant* has obtained to verify the identity of the underlying investors, and where appropriate, their beneficial shareholders, meets the requirements of our national anti-money laundering and counter-terrorist financing legislation and regulations. 3. We confirm that all documents and information, which we / the Applicant* may have on our / the Applicant s* files relating to the identity of each underlying investor will be sent to a competent authority as soon as practicable upon the competent authority s request. 4. We confirm that all documents and information, which we / the Applicant* may have on our / the Applicant s* files relating to the identity of each underlying investor will be sent to the Administrator of the ICAV as soon as practicable upon its request, subject to applicable rules and regulations. 5. We / the Applicant* will retain these documents and information for a period of at least six years after the relationship with an underlying investor has ended. 6. We / the Applicant* will take measures to ensure that the underlying investors are neither individuals nor institutions against whom sanctions have been imposed by the EU or the United Nations or persons or entities that are included on the List of Specially Designated Nationals and Blocked Persons maintained by the U.S. Treasury Department s Office of Foreign Asset Control (OFAC). 21