Appendix 1- Tender Form

Information regarding the Form:

  1. The Tender Identification Form should be drawn up as a separate document and as a file constituting an integral part of the Tender.
  2. The format in which information is to be delivered via an appendix is limited to text only (with no additional images, tables, diagrams, etc.).
  3. Editorial requirements regarding the text:
  4. document size: A4,
  5. font: Calibri,
  6. basic font size: at least 11 points,
  7. line spacing: at least 1.15,
  8. No limit is imposed as to the maximum volume (in pages) of the Form.
  9. A Tenderer other than a natural person should demonstrate the right to be represented by the indicated persons, by attaching to this Appendix an excerpt from the relevant register, extract, powers of attorney, or other corporate documents confirming the authorisation to represent the Tenderer.
  10. Where the Tenderer is a group of natural persons, the Form should take into account and be signed by all the natural persons (the lines relating to individual natural persons should be multiplied in such case).
  11. The Form should take into account all the persons in the Team (the data of all such persons should be multiplied).
  12. Relevant sections of this Form may be multiplied (copied) if the fields provided in this Form are not sufficient to present the required information.
  13. Any terms not defined herein shall have the meaning assigned to them in the Rules.

  1. First name and surname/Name of the Tenderer[1]

  1. Type of Tenderer

Managing Entity / Financial Intermediary
  1. Tenderer’s legal form[2]

  1. Type of the Financial Intermediary’s Managing Entity

natural persons who will compose the internal managing body of the Financial Intermediary, e.g. Members of the management board of the company, which after establishment and successful selection within the Call procedure will act as the Financial Intermediary
legal entities constituting the internal managing body of the Financial Intermediary, e.g.
a company which is the general partner of a partnership limited by shares, which after establishment and successful selection within the Call procedure will act as the Financial Intermediary, or
an independent external entrepreneur, authorised, under the legislation of a Member State, to manage the Financial Intermediary’s investment activities, in whole or in part (e.g. an entity that is to manage the investment portfolio, in whole or in part, of the investment fund which will act - following its establishment and successful selection, within the Call for Tenders procedure - in the capacity of the Financial Intermediary)
  1. Definition of the function of the Managing Entity in the structure of the Financial Intermediary which is to be established (e.g. the management board of a company or the general partner in
    a partnership limited by shares) and definition of the planned legal form of the Financial Intermediary[3]

  1. Contact details of the Tenderer other than a natural person[4]

Name
Address:
-Country
-Province
-County
-Municipality
-Town/city
-Street
-Building no.
-Apt. no.
-Postal code
Name of register
Number of register entry
Identification number for tax purposes
Phone number
Electronic mail (e-mail) address
  1. Contact details of the Tenderer being a natural person[5]

Name and Surname
Address of residence:
-Country
-Province
-County
-Municipality
-Town/city
-Street
-Building no.
-Apt. no.
-Postal code
Electronic mail (e-mail) address
Phone number
Identification number for tax purposes
  1. Declared Capitalisation of the Financial Intermediary

8.1Declared Capitalisation of the Financial Intermediary (in PLN)
8.1.1Amountof the Managing Entity’s contributions in the Declared Capitalization / Amount (in PLN) / % of Declared Capitalisation
8.1.2Amountof PFR Biznest FIZ contributionsassumed in the Declared Capitalisation / Amount (in PLN) / % of Declared Capitalisation
8.2Option to increase the Declared Capitalisation[6]
  1. Declaration of Co-investment of Team Members in the role of Business Angels

Yes / No
  1. Declared total level of Co-investment of Team Members in Business Angel contributions to all Investments (%)

  1. Details of the members of the Team, who have declare their work time commitment to the investment activities of the Financial Intermediary as a specified time per week[7] and/orcommitted to provide a contribution in the Declared Capitalisation of the Financial Intermediary and/or declared Co-investment in Business Angel contribution at a given level to all investments

A.Name and Surname / B. Role (Key Personnel/ other Team Member:Position) / C. Declared work time commitment tothe investment activities (hours/ week) / D.Amount contributed by the Team Member to the Financial Intermediary as part of the Managing Entity's contribution[8] / E.Ratio of the amount contributed by the Team Member to the Financial Intermediary as part of the Managing Entity's contribution to the amount of Managing Entity’s contributions in the Declared Capitalization (%)[9] / F.Ratio of Team Member’s contribution in the Business Angel contribution in each Co-investment[10]
  1. Proposed level of Carried Interest for the Managing Entity (%)

  1. Details of person(s) authorised by the Tenderer to act as contact points in relation to the Call for Tenders

First name and surname
Role/position in the Tenderer’s structure[11]
Phone number
Electronic mail (e-mail) address

The Tenderer hereby consents to the processing of its personal data contained in the present Form for the purpose of Tender assessment, in accordance with the Personal Data Protection Act of 29 August 1997 (Journal of Laws of 1997, no. 133, item 883).

SIGNATURES:

______
First name and surname of the Tenderer / person authorised to represent the Tenderer
______
Function of the signatory of this Form in the Tenderer’s structure[12]
______
Signature of the Tenderer/ Signature of the person authorised to represent the Tenderer
______
Date, place

W/02/2018

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[1]Where the Tenderer is a group of natural persons, please enter the first names and surnames of all the natural persons.

[2]Not applicable to a Tenderer being a natural person.

[3]Applicable to a Tenderer being a Managing Entity where the Financial Intermediary has not yet been established.

[4]If a Tenderer is a Financial Intermediary, please provide contact details of Managing Entity.

[5]If a Tenderer is a Financial Intermediary, please provide contact details of Managing Entity; if a Tenderer is a group of natural persons, please provide contact details of all such natural persons.

[6]According to Section 16 of the Term Sheet, the Tenderer should specify the value of any increased Declared Capitalisation where the option to increase the Declared Capitalisation is exercised (i.e. the total value of Declared Capitalisation specified under section 8.1 and the value of additional Capitalisation).

[7]Please provide contact details of all the natural persons (Team Members), who commit to provide a share in the Declared Capitalisation of the Financial Intermediary and/or declare their work time commitment to the investment activities of the Financial Intermediary as a specified time per week.

[8]The sum of amounts contributed by the Team Member to the Financial Intermediary as part of the Managing Entity's contribution must be coherent with Amount of the Managing Entity’s contributions in the Declared Capitalization, indicated inSection 8.1.1 of this Form.

[9]Amount indicated in Section 11 Dof this form (by each Team Member) divided by the amount indicated in Section 8.1.1of this form(by each Team Member)

[10]Applies if option ”Yes” is chosen in Section 9 of this Form.Amount indicated in Section 11 E of this form (by each Team Member) multiplied by the amount indicated in Section 10 of this form. Sum of percentages for all Team Members must be coherent with amount indicated in Section 10 of this form. Calculation according to Section 27 of Term Sheet

[11]Not applicable to a Tenderer being a natural person.

[12]Not applicable to a Tenderer being a natural person.