Name

Address

City

State/Province

Country

Zipcode

Phone Number

Fax Number

Email Address

Prior investing experience

Please choose one of the following ------------------------------------------------------- I am an experienced investor in alternative investments I have minimal alternative investment experience I have no prior experience with alternative investments

Domicile

Please choose one of the following ------------------------------------------------------- I am a non-US investor I am a US investor

Investment entity

Please choose one of the following ------------------------------------------------------- Individual or trust Family office Endowment/foundation Other institution None of the above

Accredited status

Please choose one of the following ------------------------------------------------------- Investable assets are less than $1.5mil Investable assets are greater than $1.5mil Investable assets are greater than $5mil Investable assets are greater than $50mil

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