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    Investment Application Form

    Before completing this investment request...

    Please see the web site for full details in regard to our investment criteria and investment process.

    A review of our existing portfolio should give you an overview of the type and stage of company that we typically invest in. If you believe you meet the investment criteria,you have two options.

    Either

    a) complete this short document in its entirety online or
    b) download the application form HERE .

    We are looking for concise answers to the requested information. Once completed, you may submit the completed online form to the Mercia Technology Seed Fund by clicking the submit button at the bottom of this form or if you are using the downloaded form, please send it by email to mail@merciafund.co.uk. We endeavour to treat all information received as confidential but we reserve the right to consult our team of associates for the purpose of evaluation. Please read the Privacy Disclaimer at the bottom of the form before submitting.

    Please complete every field. If you cannot fill a field please type N/A (Not Applicable) or N/K (Not Known)

    Contact Information
    Name:
    Position:
    Email Address:
    Company Address:
     The Mercia Technology Seed Fund can only invest in companies presently located, or prepared to relocate, in the West Midlands
    Location within the West Midlands:
    Web address of company:
    Contact phone number:
    How did you find about us? :

    Business Sector

    A1. What is your Business Sector:
    A2. What stage is your business:
    A3. Brief Description of product/platform/service/technology:
    A4. Intellectual Property Rights, IPR (e.g. patents (granted or applications), design rights, copyright etc)?
    Brief summary of IPR:
    Do you have patent protection:
    Technology
    B1. What is new and innovative about your technology?
    B2. What problem does it solve?
    B3. What Research has gone into its development?
    Time in development:
    Expense to date:
    Type of funding to date: Grants
    Business angels/private investment
    Venture Capital
    Loans

    (Other):
    B4. What is the origin of the opportunity?
    B5. Working prototype tested? give a brief description:
    B6. List key publications describing technology/product/platform
    Market
    C1. Main market and its size:
    C2. Have you performed market analysis?
    Give a brief summary of the market analysis:
    C4. Competitors - strength of competition?
    There is always competition, please list the competition and briefly state;
    (i) who they are,
    (ii) why they compete
    (iii) why you will or why you do out perform them:
    Management
    D1. Experienced commercial CEO?
    Brief pen portrait of MD/CEO (interim or otherwise):
    D2. Balanced management team?
    Brief pen portraits of the management team including founders:
    D3. Define additional human resources needed
    Finance
    E1. Company details:
    Registered office address:
    Company Registration Number:
    When was the company incorporated?:
    Auditors:
    Legal Representatives:
    Patent Agents:
    E2. Investment received to date (do not include grant funding):
    E2. Revenue from customers?
    E3. How much investment are you seeking?
    E4. Have you identified investment from other sources to meet in part the amount sought in E3?
    How much has been secured towards the amount sought in E3:
    Who have you received this preliminary commitment from:
    E5. What is your use of funds?
    Please Detail:
    - Forecasted profit and loss (for at least 3 years)
    - Forecasted cash flows (for at least 3 years)
    Year Ending
    dd/mm/yyyy
    		 Last year Current Year Next Year Year 2 Year 3 Year 4 Year 5
    Actual Actual
    Year
    to Date    		 Projected
    Total    		 Projected Projected Projected Projected Projected
    Profit &
    Loss Account    		 £ £ £ £ £ £ £ £
    Sales
    Gross Profit
    Overheads
    Depreciation
    Profit Before
    Interest & Tax
    Cashflow Items £ £ £ £ £ £ £ £
    Capital Expenditure
    Working
    Capital Movement
    - Assumptions driving the forecasts
    - Key milestones to be achieved with the investment
    E6. Anticipated exit
    The Mercia Technology Seed Fund looks to exit (i.e. sell its interest) from the investee 4-6 years post investment.
    Please list comparable businesses to yours that are either trading on public markets (e.g. AIM, LSE, NASDAQ etc) or have exited favourably through a trade sale.
    Comparable name:
    Exit price:

    You will receive a copy of the information shown on this form at the email address you provided

     


    The Mercia Technology Seed Fund is managed by WM Enterprise which is a trading name of West Midlands Enterprise Ltd. West Midlands Enterprise Ltd is authorised and regulated by the Financial Services Authority.

    Privacy and Disclaimer Statement

    This privacy policy sets out the ways Mercia Technology Seed Fund (MTSF) processes personal data. This privacy policy only relates to personal data collected by MTSF via the MTSF website, application forms, emails and telephone calls. Any personal data collected by MTSF is used in accordance with UK data protection legislation. This Privacy Policy does not apply to personal data provided to MTSF by any other means or via any other website. Users should be aware that if they access other websites, using the links provided, these are outside MTSF’s control. If they provide personal data to other companies, the privacy polices of those companies determine the uses to which that information is put and MTSF's Privacy Policy will no longer apply.

    Personal information provided to MTSF via the MTSF website, application forms, mails and telephone calls will be collected and processed by MTSF:

    • in connection with the proposed investment by MTSF in the company in relation to which the user has provided his personal data; and
    • for statistical analysis and reporting.

    We will take all reasonable steps to ensure that the data held is adequate, relevant and not excessive for these purposes. Processing personal data for the above purposes may entail sharing the information with employees, contractors, agents, potential non-executive chairman and professional advisers of MTSF. We will take all reasonable steps to retain data only for the duration of the purpose for which it was obtained but may need to hold some details about you after our dealings with you have ended. MTSF does not provide your details to third parties for any marketing or promotional purposes. By providing personal data to MTSF users consent to the processing of such data by MTSF as described in this Privacy Policy.

    If, at any time, a user wants to verify, update or amend their personal data they may write to: Mercia Technology Seed Fund, Wellington House, 31-34 Waterloo Street, Birmingham B2 5TJ

    MTSF holds your personal data in accordance with the security provisions of the UK data protection legislation. We do not use cookies for collecting user information. MTSF will notify users of any changes it makes to its Privacy Policy. If MTSF decides to change its Privacy Policy, it will post such changes on this page so that you are always aware of how MTSF uses your personal data. Users have the right to ask MTSF, in writing, for a copy of all the personal data held about them upon payment of a fee ("subject access request") and to request that MTSF correct any inaccuracies in that information.