For Individual Investors. A government issued form of picture identification (e.g., passport or drivers license). ____ Proof of the individual’s current address (e.g., current utility bxxx), if not included in the form of picture identification. ____ One or more of the above documentations has previously provided to Placement Agent.
For Individual Investors. Name: Telephone: 0; Home Address: &# 160; _______________________________________________________________________________________________________ Date of Birth: _______________________ U. S. Citizen Yes ______ No ______ Social Security Number:_________________________________________________________________________________ Occupation or Profession:_______________________________________________________________________________ Nature of Business:_____________________________________________________________________________________ Name and Address of Employer:__________________________________________________________________________ Business Telephone:____________________________________________________________________________________ Current Position or Title: Period Employed: Nature of Duties:  60; Prior Employment (if current employment is less than five years): Name of Prior Employer: Period Employed: Communications should be sent to (check one): ______ Residence ____ Business
For Individual Investors. I certify that I am a natural person whose individual net worth, or joint net worth with the person’s spouse, excluding the value of any principal residence, at the time of his purchase exceeds $1,000,000. I certify that I am an accredited investor because I had individual income in excess of $200,000 in each of the two most recent years or joint income with that person’s spouse in excess of $300,000 in each of those years and has a reasonable expectation of reaching the same income level in the current year. The Subscriber hereby certifies that it is an accredited investor because it is a trust with total assets in excess of $5,000,000, was not formed for the specific purpose of acquiring the Units offered and its purchase is directed by a sophisticated person. As used in the foregoing sentence, a “sophisticated person” is one who has such knowledge and experience in financial and business matters that he or it is capable of evaluating the merits and risks of the prospective investment. The Subscriber hereby certifies that it is a bank as defined in Section 3(a)(2) of the Securities Act, a savings and loan association or another institution as defined in Section 3(a)(5)(A) of the Securities Act, acting in a fiduciary capacity, and subscribing for the purchase of the Units being offering on behalf of a trust account or accounts. The Subscriber hereby certifies that it is a revocable trust which may be amended or revoked at any time by the grantors thereof and all of the grantors are accredited investors. The Manager, in its sole discretion, may request information regarding the basis on which such entity owners are accredited.
For Individual Investors. A government issued form of picture identification (e.g., passport or drivers license). ____ Proof of the individual’s current address (e.g., current utility bxxx), if not included in the form of picture identification. ____ One or more of the above documentations has previously provided to Placement Agent. _____ A certificate of due formation and organization and continued authorization to conduct business in the jurisdiction of its organization (e.g., certificate of good standing). _____ An “incumbency certificate” attesting to the title of the individual executing these subscription materials on behalf of the prospective investor. _____ A completed copy of a certification that the entity has adequate anti-money laundering policies and procedures (“AML Policies and Procedures”) in place that are consistent with the USA PATRIOT Act, OFAC and other relevant federal, state or non-U.S. anti-money laundering laws and regulations (with a copy of the entity’s current AML Policies and Procedures to which such certification relates). _____ A letter of reference for any entity not located in the U.S. or other FATF country, from the entity’s local office of a reputable bank or brokerage firm that is incorporated, or has its principal place of business located, in the U.S. or other FATF Country certifying that the prospective investor maintains an account at such bank/brokerage firm for a length of time and containing a statement affirming the prospective investor’s integrity. ____ One or more of the above documentations has previously provided to Placement Agent. * As of the date hereof, countries that are members of the Financial Action Task Force on Money Laundering (“FATF Country”) are: Argentina, Australia, Austria, Belgium, Brazil, Canada, Denmark, Finland, France, Germany, Greece, Hong Kong, Iceland, Ireland, Italy, Japan, Luxembourg, Mexico, Kingdom of the Netherlands, New Zealand, Norway, Portugal, Russian Federation, Singapore, South Africa, S pain, Sweden, Switzerland, Turkey, United Kingdom and the United States of America.
For Individual Investors. For Investors other than Individuals: EXHIBIT A Investor Name Total Subscription Price Number of Shares and Address Amount in US$ per Share to be Issued EXHIBIT B AMARIN CORPORATION PLC STOCK CERTIFICATE QUESTIONNAIRE
For Individual Investors. 1. ☐ The Subscriber is a natural person whose net worth, taken together with the net worth of such person’s spouse or spousal equivalent, exceeds $1,000,000;
2. ☐ The Subscriber is a natural person who had an individual income in excess of $200,000 in each of the two previous years, or joint income with such person’s spouse or spousal equivalent in excess of $300,000 in each of those years, and who reasonably expects to reach the same income level in the current year;
3. ☐ The Subscriber is a director, executive officer of Fortress Net Lxxxx XXXX or a director or executive officer of FNLR Management LLC, the Adviser, or its affiliates;
4. ☐ The Subscriber holds in good standing one or more professional certifications or designations or credentials from an accredited educational institution that the SEC has designated as qualifying an individual for accredited investor status; OR
5. ☐ The Subscriber has such knowledge and experience in financial and business matters that he/she is capable of evaluating the merits and risks of investing in the Interests.
For Individual Investors or Other Entity Investors: Accepted:
For Individual Investors. ¨ A government issued form of picture identification (e.g., passport or drivers license). ¨ Proof of the individual’s current address (e.g., current utility xxxx), if not included in the form of picture identification. ¨ A certificate of due formation and organization and continued authorization to conduct business in the jurisdiction of its organization (e.g., certificate of good standing). ¨ An “incumbency certificate” attesting to the title of the individual executing these subscription materials on behalf of the prospective investor. ¨ A completed copy of a certification that the entity has adequate anti-money laundering policies and procedures (“AML Policies and Procedures”) in place that are consistent with the USA PATRIOT Act, OFAC and other relevant federal, state or non-U.S. anti-money laundering laws and regulations (with a copy of the entity’s current AML Policies and Procedures to which such certification relates). ¨ A letter of reference any entity not located in the U.S. or other FATF country, from the entity’s local office of a reputable bank or brokerage firm that is incorporated, or has its principal place of business located, in the U.S. or other FATF Country certifying that the prospective investor maintains an account at such bank/brokerage firm for a length of time and containing a statement affirming the prospective investor’s integrity.
For Individual Investors. Subscriber represents that he or she has an individual net worth, or together with his or her spouse a combined net worth, in excess of $1,000,000. For purposes of this representation, “net worth” means the excess of total assets (exclusive of primary residence but inclusive of the excess indebtedness on such residence over its fair market value) at fair market value over total liabilities.
For Individual Investors. For Investors other than Individuals:
