Name *

First Name

Last Name

Phone *

Country

(###)

###

####

Have you had an individual income exceeding $200,000 in each of the past two years, and do you reasonably expect to earn an individual income exceeding $200,000 this year? *

Yes

No

Have you had a joint income with your spouse exceeding $300,000 in each of the past two years, and do you reasonably expect to earn a joint income exceeding $300,000 this year? *

Yes

No

Is your individual or joint net worth with your spouse over $1,000,000, excluding the value of your primary residence? *

Yes

No

Do you hold any of the following professional certifications, designations, or credentials that the SEC has designated as qualifying for accredited investor status? *

Licensed General Securities Representative (Series 7) Licensed Investment Adviser Representative (Series 65) Licensed Private Securities Offerings Representative (Series 82)

Yes

No

Are you a knowledgeable employee of a private fund? *

Yes

No

Are you an executive officer, director, or a general partner of the company issuing the securities being offered or sold, or an executive officer, director, or general partner of a general partner of that issuer? *

Yes

No

Is the investor a bank, insurance company, registered investment company, business development company, or small business investment company? *

Yes

No

Is the investor a business in which all the equity owners are accredited investors? *

Yes

No

Is the investor an employee benefit plan, trust, charitable organization, partnership, or company with assets exceeding $5,000,000? *

Yes

No