Has Investment Adviser completed this form within the last 12 months? Yes No
· If Yes, has any of the information previously provided changed? Yes No
If Yes, please update the relevant section(s) of this form.
1. INVESTMENT ADVISER INFORMATION - BACKGROUNDFull Entity Name (Account name) :
Name in Local Language if applicable: / Company ID No.:
Primary Contact Name/ Title:
/ Email:
Phone Number: / Fax No.:
Primary Place of Business Street Address:
City, State/Province: / Country/Postcode
Website (if any):
Entity is incorporated under the Laws of (state/country):
Investment Adviser Type: Start-up Existing Expected Funding Date:______
If existing, please list nature of existing relationships:
2. ENTITY & REGISTRATION TYPE
Check each box applicable to the Investment Adviser:
Private Corporation / Partnership
Limited Partnership / Limited Liability Company
Trust
Registered Broker Dealer/Investment Adviser/Entity (Provide name and Country) / Registration No.:______
Application pending Date expected:______
Exchange Regulated Entity (i.e. HKEx)
(Provide name, type of registration and country): / Registration No.:______
Application pending Date expected:______
Bank Authority Regulated Entity(i.e. HKMA)
(Provide name and country) / Registration No.:______
Application pending Date expected:______
Affiliate of a Registered Broker-Dealer/Investment Adviser or an entity registered with Exchange/Banking Authority (Please list names/Countries):
None of the Above. Please notify your GSS representative if none of these categories seem applicable.
3. PRINCIPAL BACKGROUND
Complete the following section for ALL Key Principals of the Investment Adviser including. A Principal is generally a senior or executive officer, manager, managing member, general partner, an employee in charge of a principal business unit, division or function, or an employee who performs a significant policy-making function including the CFO and COO and CCO (Chief Compliance Officer)
· If new Principals become associated with the Entity, please notify the GSS personnel responsible for the relationship.
NOTE: For each principal, please copy this section and complete as applicable
First Name / Last Name / Middle Initial / Local Character name (if any)
Job Title:
Date of Birth: / Passport No/ID No. (include country of Issue)
Address/City/State or Province / Country
Employment History (Past 10 years, continue on separate sheet if necessary):
NOTE: A detailed CV containing all of the below information may be provided in lieu of completing this section
Company Name
Address/Country / Job Title/position / Tenure (From Mo/Yr To Mo/Yr) / Contact Person
Telephone Number
Education Information (include undergraduate and graduate studies):
NOTE: A detailed CV containing all of the below information may be provided in lieu of completing this section
University
Address / (From Mo/Yr To Mo/Yr) / Degree Awarded
Year
4. POLITICALLY EXPOSED PERSON
Check box if any Principal of this entity is a Politically Exposed Person (“PEPs”), defined as any one of the following:
· A current or former senior official in the executive, legislative, administrative, military, or judicial branches of a government;
· A senior official of a major political party;
· A senior executive of a government-owned commercial enterprise;
· A person who is widely and publicly known (or is actually known by
the Firm) to be a close associate of an individual exercising any of the functions listed above; or,
· An immediate family member of an individual exercising any of the functions listed above.
If checked, provide title/position, country, and dates of service (current and past):
5. FORMER GOLDMAN SACHS EMPLOYEES
Check box if any Principals of this entity have been previously employed by Goldman, Sachs & Co. or any of its affiliates.
If checked, provide the name of the Principal(s), name(s) of the employing Goldman entity, location and dates of employment (if not already provided in Employment Section or CV):
6. LITIGATION/REGULATORY DISCLOSURE
Please provide disclosure of any pending litigation, law enforcement or regulatory matters against the Investment Adviser or against any of the Investment Adviser’s affiliates or any of the Investment Adviser’s associated Funds. (Provide nature of action, regulatory agency/court location, date of action)
Attach additional pages if necessary
7. SERVICE PROVIDER INFORMATION
A. Outside Auditor for the Investment Adviser’s Fund Clients (Existing Funds)
Name:
Address
City: / State/Zip code: / Country
Phone Number: / Email: / Years of Service
B. Outside Counsel for the Investment Adviser’s Fund Clients (New and Existing Funds)
Name:
Address
City: / State/Zip code: / Country
Phone Number: / Email: / Years of Service
C. Fund Administrator for the Investment Adviser’s Fund Clients (Existing Funds)
Name:
Address
City: / State/Zip code: / Country
Phone Number: / Email: / Years of Service
D. Are any Principals/employees of the above referenced service providers also Principals/employees of the Investment Adviser? Yes No
If yes, please explain:
E. Is the Investment Adviser otherwise affiliated with any of the services providers identified above? Yes No
If yes, please explain:
F. Have any service providers declined or resigned from providing services in the past 10 years. Yes No
If yes, please explain:
Goldman’s Use of Information
All of the non-public information provided to Goldman, Sachs & Co. (together, with its present and future affiliates, (“GS”) in response to this form (the “Information”) will be used by GS or its agent to contact past employers, educational institutions, and personal references (including employment history) of the Principals to verify the Information’s accuracy, as well as to research additional information relating to the background of the Principals and the Investment Adviser, and to share such information with GS affiliates, agents, and service providers of GS to determine eligibility for the establishment now or in the future of a direct or indirect relationship between GS and the investment advisor named herein or any of its affiliates.
Neither GS nor its agent will contact anyone it knows to be currently associated with a Principal’s present employer without that Principal’s prior approval.
GS will not disclose the Information outside of GS except (1) for the purposes described above, (2) in connection with a judicial, administrative or regulatory proceeding, inquiry or audit in which GS or a partner, officer, director, or employee of GS is involved, (3) as necessary to comply with law, or (4) to the extent applicable, in connection with GS’ role as underwriter, dealer, agent or similar participant of any offering of securities by the investment advisor named herein or one of its affiliates.
Please refer to the Personal Data (Privacy) Ordinance Notice provided to you for more information.
Certification
By signing below, the person completing this form on behalf of the Investment Adviser certifies that the information provided in this form is true and complete to the best of his or her knowledge.
Signed :
Name:
Title:
Date form completed:
APPENDIX A
AUTHORIZATION TO VERIFY BACKGROUND
(Please copy this page and sign for each principal)
I certify that all of the non-public information that I have provided or will provide to Goldman Sachs International (together, with its present and future affiliates, “GS”) about myself in response to the GSS Investment Adviser Due Diligence Form (the “Information”) is complete and true to the best of my knowledge. I authorize GS or its agent to contact my past employers, educational institutions, and personal references to verify the information provided (including employment history), as well as research additional information relating to my background, and to share such information with affiliates, agents, and service providers of GS to determine eligibility for the establishment now or in the future of a direct or indirect relationship between GS and any entity with which I am currently or subsequently associated or any of its affiliates.
I understand that neither GS nor its agent will contact anyone it knows to be currently associated with my present employer without my prior approval; I also understand that I have been asked to provide my date of birth, social security or other government-issued identification number to verify my academic credentials and for purposes of conducting additional research regarding my background.
I provide this information with the understanding that GS or its agent will not disclose the Information except (1) for the purposes described above, (2) in connection with a judicial, administrative or regulatory proceeding, inquiry or audit in which GS or a partner, officer, director, or employee of GS is involved, (3) as necessary to comply with law, or (4) to the extent applicable, in connection with GS’ role as underwriter, dealer, agent or similar participant of any offering of securities by the entity with which I am currently associated or any of its affiliates.
I have also received and read a copy of the Personal Data (Privacy) Ordinance Notice provided by GS.
_
Full Name (First Middle Last) Date of Birth
Local Character Name (if applicable) Government ID #
Signature:
Date:
APPENDIX B (Existing Funds)
RELEASE OF INDEPENDENT AUDITOR’S REPORTS
We authorize our Independent Auditor, , to release to Goldman Sachs International, Goldman Sachs (Asia) LLC, or their agents or affiliates, the Independent Auditor’s Report for the below Fund(s), including any related qualifications, disclaimers or explanatory language, for the most current period.
List Fund(s) here:
Signature
Print Name
Title/Position
Date
APPENDIX C (Existing Funds)
RELEASE OF THIRD PARTY SERVICE PROVIDER INFORMATION
(Please copy and prepare for each Service Provider listed in Section 7)
We authorize our Service Provider, , to release to Goldman Sachs International, Goldman Sachs (Asia) LLC, or their agents or affiliates, the nature of the existing relationship and the years of service with the Investment Advisor.
Investment Advisor Name
Signature of Principal
Print Name
Title/Position
Date