NEW INVESTOR PROFILE

First Name *

Last Name *

Email *

Phone *

Address

Street Address *

City *

State *

Country *

Postal code *

Subscriber Type *

Individual

Entity/Trust/LLC

Entity Name *

Title / Position *

INVESTMENT TERMS

Principal Investment* *

Preferred Payment Method *

Preferred Communication Method *

Email

Phone

By checking the applicable box(es) below and signing this form, I hereby certify, under penalty of perjury, that I am an “accredited investor” as defined under Rule 501(a) of Regulation D of the Securities Act of 1933, because I qualify under one or more of the following categories:

For Entities (check all that apply:) *

I am a director, executive officer, or general partner of the Issuer.

The entity has total assets in excess of $5,000,000.

The entity’s equity owners are all accredited investors.

I am a Series 7 license-holder.

I am a Series 65 license-holder.

I am a Series 82 license-holder.

For Individual Investors (check all that apply:) *

My individual income exceeded $200,000 in each of the two most recent years, and I reasonably expect the same in the current year.

My joint income with my spouse exceeded $300,000 in each of the two most recent years, and I reasonably expect the same this year.

My individual net worth, or joint net worth with my spouse, exceeds $1,000,000 (excluding primary residence value).

ACKNOWLEDGEMENT

By checking this box, I consent to receive transactional messages related to the services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

By checking this box, I understand that the Issuer will rely on the certification in this form and Subscriber Agreement to verify my status for participation in the above-referenced offering. I agree to provide accreditation documentation upon request.

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