Camino Real Angels' Membership Form

First Name:

Last Name:

Address:

City

State

Zip

This Address is:

Home Business

	Please enter phone numbers as (xxx)xxx-xxxx
Day Phone		Day Fax	Cell Phone
Evening Phone		Evening Fax	Pager
Alt Phone		Email		Network
Company
Title

Referral to Camino Real Angels:

How did you learn about CRA? Are you known to any CRA members?

Business Experience:

Describe your business experience and significant accomplishments. Include companing, positions held and dates. Describe the business skills you have that would be of benefit to CRA or the companies we fund.

Private Investment Experience:

List and descrive specific investments you have made in private companies and descrive any active roles you have taken (mentor, director, incubator).

Board Experience:

List public and private boards that you have served on and the dates of service.

Education:

Affiliations:

Family, Personal Interests:

Investment Experience Indicate the areas where you have had prior experience. (Check all that apply):
	Originated Deals	Negotiated/Structured Deals
	Served on Boards	Reviewed Business Plans
	Due Diligence - Lead Effort	Due Diligence - Participated
	Attended Deal Forums

Industry Technology Investment Experience Indicate the areas where you have had prior experience (Check all that apply):
	Communications, Networking	Computers, Peripherals
	Software	Electronics, Components
	Optics	Test & Measurement
	Semiconductors, Equipment	Internet Business Services
	e-Commerce	Internet Infrastructure
	Internet Software/Database	Internet Content
	Information Services	Other Information Technology
	Medical Devices, Equipment	Medical Information Systems
	BioPharmaceuticals	Healthcare Services
	Other Healthcare	Specialty Materials, Chemicals
	Energy, Environmental	FInancial Services
	Publishing, Media	Education, Training
	Manufacturing	Industrial Products
	Aviation	Consumer Products, Services
	Retail	Real Estate
	Professional Services	Other

Industry Technology Investment Interest Indicate the areas where you have a current investment interest (Check all that apply):
	Communications, Networking	Computers, Peripherals
	Software	Electronics, Components
	Optics	Test & Measurement
	Semiconductors, Equipment	Internet Business Services
	e-Commerce	Internet Infrastructure
	Internet Software/Database	Internet Content
	Information Services	Other Information Technology
	Medical Devices, Equipment	Medical Information Systems
	BioPharmaceuticals	Healthcare Services
	Other Healthcare	Specialty Materials, Chemicals
	Energy, Environmental	FInancial Services
	Publishing, Media	Education, Training
	Manufacturing	Industrial Products
	Aviation	Consumer Products, Services
	Retail	Real Estate
	Professional Services	Other

Operating Experience Indicate operating positions you have held (Check all that apply):
	CEO	COO
	VP Marketing	VP Sales
	VP Operations	VP Engineering
	CTO / CIO	CFO
	VP Manufacturing	Partner - Law Firm
	Partner - Accounting	Partner - VC Firm
	Partner - Other Services	Board Member

Functional Experience Indicate the areas where you have strong functional expertise (Check all that apply):
	General Mgmt	Strategic Planning
	Fund Raising	Organizational Development
	Marketing - Consumer	Marketing - B2B
	Advertising	Sales - OEM, Major Account
	Sales - Direct, Retail	International Sales, Marketing
	Hardware Development	Software Development
	Manufacturing	Operations
	Logistics	Quality
	Finance, Accounting	Information Technology
	Legal, Agreements	Negotiations

Planned CRA Involvement Indicate the areas where you expect to contribute to CRA (Check all that apply):
	Originate Deals	Negotiate/Structure Deals
	Serve on Boards	Review Business Plans
	Due Diligence - Lead Effort	Due Diligence - Participate
	Attend Screening Sessions	Lead Screening Sessions

Legal Filings:

List and explain any litigation (as plaintiff or defendant) either personal or business during the past ten years. List and explain any FTC, SEC or other Federal/State or other regulatory proceedings filed against you. List and explain any bankrupcy filings, either personal or for an entity for which you have served as an officer or director.

Investment Expectations:

How many investments and in what amounts would you expect to make in CRA deals in a 24 month period? On average, how many hours per week would you expect to devote to CRA activities? What other contributions might you make to the organization?

I meet the SEC requirements of an accredited investor.
	Yes No

May we disclose that you are a Camino Real Angels member in news articles and PR?
	Yes No