Common use of PLEASE PROVIDE THE FOLLOWING INFORMATION Clause in Contracts

PLEASE PROVIDE THE FOLLOWING INFORMATION. (a) Name of Preferred Stock Holder: _____________________________________________________ (b) If Preferred Stock Holder is a corporation, partnership, trust or other entity, state the name of the individual(s) making the investment decision on behalf of the entity: _____________________________________________________ 2. Preferred Stock Holder’s Address: _____________________________________________________ _____________________________________________________ _____________________________________________________ 3. Telephone Number (including country and area code): _____________________________________________________ 4. Taxpayer Identification Number of Purchaser: _____________________________________________________ 5. Jurisdiction and date of organization or incorporation: _____________________________________________________ 6. Is the Preferred Stock Holder a new or an existing shareholder? _____________________________________________________

PLEASE PROVIDE THE FOLLOWING INFORMATION. (a) Name of Preferred Stock Holder: ____________________________________________________________________________ (b) If Preferred Stock Holder is a corporation, partnership, trust or other entity, state the name of the individual(s) making the investment decision on behalf of the entity: ____________________________________________________________________________ 2. Preferred Stock Holder’s Address: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 3. Telephone Number (including country and area code): ____________________________________________________________________________ 4. Taxpayer Identification Number of Purchaser: ____________________________________________________________________________ 5. Jurisdiction and date of organization or incorporation: ____________________________________________________________________________ 6. Is the Preferred Stock Holder a new or an existing shareholder? ____________________________________________________________________________