1.) PERSONAL BACKGROUND INFORMATION

2.) OVERALL INVESTMENT STRATEGIES

3.) RISK TOLERANCE

4.) PRIMARY SOURCE OF INCOME:

5.) PRIOR INVESTMENT EXPERIENCE

6.) CERTIFICATION OF SOPHISTICATED INVESTOR STATUS

7.) CERTIFICATION OF ACCREDITED INVESTOR STATUS

I acknowledge and warrant that I am an “accredited investor” for the following reasons: (a) My individual net worth, along with the net worth of my spouse exceeds $1,000,000, excluding the value of my personal residence and excluding from my liabilities the mortgages of my primary residence, provided the mortgages to not exceed the value of my primary residence (b) My individual income was in excess of $200,000 in each of the past two years (excluding my spouse’s income) and I expect to have income (excluding my spouse’s income) in excess of that amount in the current year or my individual income for each such years together with my spouse’s is in excess of $300,000 each

8.) DATE AND SIGNATURE CONFIRMATION (required)

I confirm, by typing my name in below and electronically submitting this form, that the information supplied herein is current and accurate. I agree to sign a printed copy if asked to do so by recipient.