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FREE CONSULTATION

Investor Application

Please answer each question fully and attach additional information if necessary. If the answer to any question is “None” or “Not Applicable”, please so state. Please sign and date this Questionnaire on the final page.

(1)
(2) Investment History and Sophistication
(3) Check one of the following representations (a) through (c), if applicable.
(i)
(ii)
(iii)
(iv)
(v)
(4) The undersigned represents and warrants to the Company that the information contained in this Questionnaire is true, complete and correct.
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