Name in Native Language:
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Gender:
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Current Residence Address:
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Home Telephone:
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Mobile Telephone:
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Email Address:
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Date of Birth:
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Residence 1:
Residence 2:
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Occupation:
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Number of Years:
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Present Employer:
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Business Address:
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Business Facsimile:
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Question 1:
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I certify that I am not a “U.S. Person” as defined in Rule 902 of Regulation S under the Securities Act of 1933, as amended (the “Act”), and agree to resell the securities of the Company received in connection herewith only in accordance with the provisions of Regulation S, pursuant to registration under the Act or pursuant to an available exemption from registration, and agree not to engage in hedging transactions with regard to the securities unless in compliance with the Act.
Question 2A:
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I am an “accredited investor” as defined in Rule 501 of Regulation D under the Act because I have a net worth (or joint net worth with my spouse) in excess of US$1,000,000. For purposes of this question, “net worth” means the excess of total assets (excluding value of primary residence ) over total liabilities.
Question 2B:
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I am an “accredited investor” as defined in Rule 501 of Regulation D under the Act because I have had individual income in excess of US$200,000 (excluding my spouse) in each of the two most recent years (or joint income with my spouse in excess of US$300,000 in each of those years), and have a reasonable expectation of reaching the same income level in the current year.
Question 3A
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I have the capacity to evaluate the merits and risks of the prospective investment and to otherwise protect my own interests in connection with the prospective investment by reason of my own business and/or financial experience.
If answered “YES” to the question above, I support my reply with the following education and/or business and/or financial experience:
Question 3B:
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I have hired a professional advisor, and by reason of the business and/or financial experience of such professional advisor, I have the capacity to evaluate the merits and risks of the prospective investment and to otherwise protect my own interests in connection with the prospective investment. I understand that the professional advisor will be required to fill out and certify a questionnaire.
Question 4
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I am purchasing the securities offered for my own account and for investment purposes only.
If I answered “NO” to the question above, the following is the person for whose account I am purchasing the offered securities and/or the reason for investing:
Question 5:
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I have a pre-existing personal or business relationship with the Company or any of its officers, directors, or controlling persons.
If I answered “YES” to the question above, I explain my reply with the following description of my affiliation with that person or those persons:
