Title:

Company:

Address:

E-Mail:

Phone:

Nature of Inquiry:

Comments:

I am a U.S.-natural person and own not less than $5,000,000 in investments.

I am a U.S.-person, acting for my own account or the account of another, and own and invest on a discretionary basis not less than $25,000,000 in investments.

I am not a resident of the United States.