Oxford Capital

Please answer all questions and if a question is answerable in the negative, please answer "No". Do not leave any section blank.

In this form, the term "company" includes any company or corporation wherever incorporated and "director" includes a person in accordance with whose directions or instructions the company's directors are or were accustomed to act.

Present surname and any former surname(s)

Present forename(s) and any former forename(s)

Professional qualifications, if any

2. Are you or your spouse a director of any other companies?

3. Please state the names, nature of (and, where appropriate, termination) of all shareholdings (other than listed companies of whose shares you hold or have held less than 1%) or partnerships or proprietorships of companies which you or spouse hold or have held.

4. Is any company of which you or your spouse is or has been a director, shareholder, partner or proprietor presently a party (or likely to become a party) to any litigation or court proceedings which may or will have a significant effect on the financial position of that firm?

5. Have you or your spouse at any time been adjudged bankrupt or had a bankruptcy petition filed, or served or presented either in the United Kingdom or elsewhere?

6. Have you or your spouse at any time been a party to a deed of arrangement or made any other form of composition with your creditors?

7. Have you or your spouse at any time been a party or presently are a party, to any litigation or court proceedings?

8. Have you or your spouse at any time been a party or presently are a party, to any litigation or court proceedings?

9. Are there any unsatisfied judgments outstanding against you or your spouse?

10. Have you or your spouse ever been the subject of a claim for unpaid taxes?

11. Have you ever been “blacklisted” by any stockbroker, the Financial Services Authority or by the London Stock Exchange or any other investment exchanges?

12. Has any company been put into liquidation (otherwise than by a members' voluntary winding up when the company was solvent) or had a receiver appointed during the period when you or your spouse were (or within the preceding six months had been) one of its directors?

13. Have you or your spouse at any time been convicted in the United Kingdom or elsewhere of any offence involving fraud or dishonesty or an offence under legislation (whether or not of the United Kingdom) relating to companies (including insider dealing), building societies industrial and provident societies, credit unions, friendly societies, insurance, banking or other financial services, insolvency, consumer credit or consumer protection?

14. Have you or your spouse ever been concerned with the management or conduct of affairs of any company which to your knowledge is being or has at any time, while you have been concerned with the company, been inspected by any inspector with statutory authority?

15. Have you or your spouse ever been disqualified by a court from being a director of any corporation?

16. Are you or your spouse or have you or your spouse ever been the subject of an investigation or litigation in the United Kingdom or elsewhere or are there circumstances of which you are aware as a result of which you may become the subject of any investigation or litigation?

17. Have you or your spouse, in connection with the formation or management of any body corporate, partnership or unincorporated institution been adjudged by a court in the United Kingdom or elsewhere civilly liable for any fraud, misfeasance or other misconduct by you towards such a body or company or towards any members thereof?

18. Have you, in the United Kingdom or elsewhere, been refused to be admitted to membership of any professional body or been censured or disciplined by any such body to which you belong or belonged or have you held a practising certificate subject to conditions?

19. Please confirm that you are not currently, and that you have never been, a director, shareholder, partner or proprietor or otherwise associated with any company which carries on or has carried on business similar to or in competition with the Company?

20. Please supply a list of the names of your employers during the last fifteen years and the dates during which you worked for them, together with a short description of your job and your job title, and reason for leaving each place of employment

Have you ever been dismissed from any office or employment?

Please give details of any restrictive convenants or other obligations by which you are still bound by reason of any previous employment

21. Do you suffer or have you ever suffered from any serious disease or illness or disability or has any application for life or health assurance made by you been turned down or accepted on special terms?

22. Please attach details of all payments (whether of dividend, salary or any form of charge or repayment) received by you, any member of your family or any other person, partnership or company associated with you, from the Company or any of its group in the last 12 months and those likely to be received as aforesaid by you and such persons in the next 12 months and details of all loans from and to the Company and its group to and from you or such persons

23. Please give details of all borrowing and any other undischarged debts

24. Are you satisfied that you and your spouse have the financial resources to meet your existing and anticipated financial liabilities?

25. Are there any other facts or circumstances relating to you or your spouse and your respective business careers which could be relevant to a prospective venture capital funder in the Company or be material for consideration in the context of the Company’s business plan?

26. Are there any other facts or circumstances that could in any way impair your suitability to be a director of a private company?

27. Please supply to us a copy of your passport and one utility bill (less than 3 months old)

28. Please nominate one Director to supply a certified copy of the Company’s certificate of incorporation, together with evidence of the registered address of the Company and a list of its shareholders and directors

I, of a director of declare that the answers to all of the above questions (including any documents produced as part of an answer) are true

OxfordCapital

Declaration with regard to directors and partners

Company Name (subsequently referred as the 'Company')

1.