Name *

First Name

Last Name

Phone *

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This strategy is for accredited investors only. Please certify how you qualify. *

(Check One)

Net worth over $1 million, excluding primary residence (individually or with spouse or partner).

Income over $200,000 (individually) or $300,000 (with spouse or partner) in each of the prior two years, and reasonably expects the same for the current year.

Investment professionals in good standing holding the general securities representative license (Series 7), the investment adviser representative license (Series 65), or the private securities offerings representative license (Series 82).

Directors, executive officers, or general partners (GP) of the company selling the securities (or of a GP of that company).

Any “family client” of a “family office” that qualifies as an accredited investor.

The following entities with assets in excess of $5 million: corporations, partnerships, LLCs, trusts, 501(c)(3) organizations, employee benefit plans, “family office” and any “family client” of that office.

I am a tax professional, CPA, EA or attorney. *

Yes

Not Applicable