Application Forms

Investor application forms for Existing Investors, Individuals, Joint Investors, Companies, Australian Family and Charitable Trusts, and Superannuation Funds.

*A signed Certificate by a Qualified Accountant is required to be submitted with all applications. The form can be downloaded from the link below and uploaded in the space provided at the end of the application form.

Download Document

Investor Application

For: Existing Investors, Individuals, Joint Individuals, Companies, Australian Family and Charitable Trust, and Superannuation Funds.

Please select your investment type*
Existing Investor Application
Investor Account Name*
Individual Investor
Name*
First Last
Country of Birth*
Date of Birth*
Enter DOB in the format: ddmmyyyy
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Australian Tax File Number*
Australian Passport Number or Driver's Licence*
Contact Telephone Number*
Email Address*
IDENTIFICATION DOCUMENTATION
For identification purposes we require an original certified copy of a passport or drivers licence. To verify your identity these documents can be certified by a Justice of the Peace, Doctor, Dentist, Lawyer, Physiotherapist, Pharmacist, Police Officer, Teacher, Accountant or Australia Post Officer.
*Documents can be uploaded in the space provided at the end of the application form.
Joint Investors
Name of Investor 1*
First Last
Country of Birth*
Date of Birth*
Enter DOB in the format: ddmmyyyy
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Australian Tax File Number*
Australian Passport Number or Driver's Licence*
Name of Investor 2*
First Last
Country of Birth*
Date of Birth*
Enter DOB in the format: ddmmyyyy
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Australian Tax File Number*
Australian Passport Number or Driver's Licence*
Contact Telephone Number*
Email Addresses*
IDENTIFICATION DOCUMENTATION
For identification purposes we require an original certified copy of a passport or drivers licence. To verify your identity these documents can be certified by a Justice of the Peace, Doctor, Dentist, Lawyer, Physiotherapist, Pharmacist, Police Officer, Teacher, Accountant or Australia Post Officer.
*Documents can be uploaded in the space provided at the end of the application form.
Company Application
Company Name*
ACN/ABN*
Australian Tax File Number*
Registered Street Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Registered Place of Business Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Do any US citizens or residents have a beneficial interest in more than 25% of the company?*
- Yes
- No
Is the company a financial institution?*
- Yes - please provide the Global Intermediary Number (GIN)
- No
(GIN)
Please upload a current company extract.
Accepted file types: pdf, Max. file size: 100 MB.
IDENTIFICATION DOCUMENTATION
For identification purposes we require an original certified copy of a passport or drivers licence for each director of the company. To verify your identity these documents can be certified by a Justice of the Peace, Doctor, Dentist, Lawyer, Physiotherapist, Pharmacist, Police Officer, Teacher, Accountant or Australia Post Officer.
*Documents can be uploaded in the space provided at the end of the application form.
Investor Contact and Communication*
First Last
Contact Telephone Number*
Email Address*
Postal Address*
Australian Family & Charitable Trust Application
Trustee: Company or Individual (s) Name and Date of Birth*
ACN/ABN of Trustee*
Australian Tax File Number*
Registered or Full Street Address of all Trustees*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Principal Place of Business Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Trust Name*
Country in which Trust Established*
ABN*
Australian Tax File Number*
Registered Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
IDENTIFICATION DOCUMENTATION
For identification purposes we require an original certified copy of a passport or drivers licence for the trustees of the trustee company, or the individuals as trustee. To verify your identity these documents can be certified by a Justice of the Peace, Doctor, Dentist, Lawyer, Physiotherapist, Pharmacist, Police Officer, Teacher, Accountant or Australia Post Officer.
Please also provide an original copy of the pages of the trust deed that include the cover page, full name of the trust, the type of trust, the trustee (s), the settlor, the appointer, the beneficiaries and the signatures.
*Documents can be uploaded in the space provided at the end of the application form.
Please upload the trust deed.
Accepted file types: pdf, Max. file size: 100 MB.
(If the trustee is a company) Please upload a current company extract.
Max. file size: 100 MB.
Are any of the directors, trustees, shareholders, beneficiaries, settlors or appointers of the trust, trustee or a beneficiary company a US citizen or resident for tax purposes?*
- Yes
- No
Investor Contact and Communication*
First Last
Contact Telephone Number*
Email Address*
Postal Address*
Superannuation Fund Application
Trustee: Company or Individual (s) Name and Date of Birth*
ACN/ABN if Trustee is a Company*
ABN of Superannuation Fund*
Australian Tax File Number*
Registered Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Please upload the trust deed.
Accepted file types: pdf, Max. file size: 100 MB.
(If the trustee is a company) Please upload a current company extract.
Accepted file types: pdf, Max. file size: 100 MB.
IDENTIFICATION DOCUMENTATION
For identification purposes we require an original certified copy of a passport or drivers licence for the trustees of the trustee company. To verify your identity these documents can be certified by a Justice of the Peace, Doctor, Dentist, Lawyer, Physiotherapist, Pharmacist, Police Officer, Teacher, Accountant or Australia Post Officer.
*Documents can be uploaded in the space provided at the end of the application form.
Investor Contact and Communication*
First Last
Contact Telephone Number*
Email Address*
Postal Address*
Hidden
FINANCIAL DETAILS FOR ALL FORMS
Distribution Options*
- 100% cash credited to the nominated financial institution account detailed below
- 100% reinvested
Please only select one.
*Financial institution account details for redemption proceeds and if elected distributions
Financial Institution
Account Name (must be same as application name)
BSB Number
Account Number
Application Amount (Australian Dollars)*
Date funds are being transferred*

Day
Month
Year
FUNDS ARE TO BE PAID INTO THE FOLLOWING BANK ACCOUNT:
Account: Blockchain Assets Pty Ltd ATF Blockchain Early Opportunities Fund
BSB: 066 000
Account Number: 1232 6330
SWIFT: CTBAAU2S
Please reference your name on the funds transfer.
Future Instructions for Multiple Signatories*
- All signatures required
- Any one signature required
Please only select one.
Declaration*
By ticking the checkbox you agree to the declaration below.
I/We declare and agree that:

1. All details in this Application are true and correct;
2. I am/we are over 18 years of age;
3. If this Application is signed under Power of Attorney, the Attorney declares that he/she has not received
notice of revocation of that power. An original certified copy of the Power of Attorney should be submitted
with this Application;
4. I/we have read and understand the current Product Disclosure Statement, to which this Application
relates, and agree to be bound by the Scheme Constitution;
5. I/we acknowledge that no guarantee is made either as to the return of capital or the investment
performance of the Blockchain Early Opportunities Fund and understand that I/we may lose capital
depending on movements in world financial markets;
6. My/our information will be collected and used in accordance with Blockchain Assets Pty Ltd Privacy
Policy;
7. I am/we are not aware and have no reason to suspect that the moneys used to fund our investment have
been or will be derived from or related to any money laundering, terrorism financing or similar illegal
activities, that I/we will continue to comply with Australian anti-money laundering and counter-terrorism
financing laws, and declare that I am/we are not a ‘politically exposed’ person or organization under these
laws;
8. I/we will provide Blockchain Assets Pty Ltd with any additional information requested in order for this
Application to comply with any laws and regulations of Australia;
9. Blockchain Assets Pty Ltd may refuse any Application for investment in the Blockchain Early Opportunities Fund.
Name*
First Last
Date*
DD slash MM slash YYYY
Please upload completed and signed document: Certificate by a Qualified Accountant*
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

Legal Documents

Blockchain Assets Pty Ltd

Blockchain Assets Pty Ltd is a Corporate Authorised Representative (CAR No. 001293747) of M.H. Carnegie & Co. Pty Ltd (AFSL No. 411216)

T: + 61 (0) 450 900 151
E: [email protected]

This website is not for the purpose of Advertising or Promotion

This website is for information and educational purposes only. Nothing on the site should be considered advertising or promotion of cryptoassets generally or of the Blockchain Early Opportunities Fund in particular.

Furthermore, nothing on this website should be construed, directly or indirectly, as an offer or intended offer of securities.

For information about investing in cryptoassets please refer to your independent financial advisor or these Australian Government Warnings.

Application Forms

Investor Application

Existing Investor Application

Individual Investor

Joint Investors

Company Application

Australian Family & Charitable Trust Application

Superannuation Fund Application

FINANCIAL DETAILS FOR ALL FORMS

Blockchain Assets Pty Ltd

This website is not for the purpose of Advertising or Promotion