Subscriber Questionnaire. The Subscriber understands that the Company is relying on the accuracy and completeness of the information furnished by the Subscriber, among other reasons, to establish that (i) the proposed offer and sale of the Shares is exempt from registration under the 1933 Act, meets the requirements of applicable state securities laws, or both, (ii) the assets of the Company do not constitute “plan assets” for purposes of ERISA or any Similar Law, (iii) the proposed offer and sale of the Shares is not a non-exempt prohibited transaction under Section 406 of ERISA, Section 4975 of the Code, or any Similar Law, and (iv) each of the Company, the Adviser and their respective affiliates is in compliance with any law, rule, regulation, executive order or policy applicable to such person (including without limitation any anti-money laundering laws, the USA PATRIOT Act or any privacy laws). This Subscriber Questionnaire contains five parts. Prospective Subscribers should complete all applicable parts (including the Subscriber Signature Page) and provide additional documentation where indicated. · Section A: General Information (to be completed by all Subscribers) · Section B: Subscriber Qualification and Consent to Electronic Delivery of Periodic Reporting and/or Tax Information (to be completed by all Subscribers) · Section C: Supplemental Information for Individuals (to be completed by all Subscribers that are natural persons) · Section D: Supplemental Information for Entities (to be completed by all Subscribers that are entities) · Section E: Subscriber Signature Page (to be completed by all Subscribers) Capitalized terms used but not otherwise defined herein shall respectively bear the meanings ascribed to them in the Subscription Agreement to which the Subscriber Questionnaire is attached.
Subscriber Questionnaire. 1. The exact name that your shares are to be registered in. You may use a nominee name if appropriate: _____________________________________________________________________________________________
Subscriber Questionnaire. Each Subscriber shall answer the questions set forth in the Subscriber Questionnaire (“Subscriber Questionnaire”) in the form attached as Exhibit C and deliver such completed Subscriber Questionnaire to the Company on or prior to the Closing Date. The Subscriber represents that the information provided therein shall be true and correct as of the Closing Date and the date such Subscriber Questionnaire is delivered to the Company.
Subscriber Questionnaire. Each Seller shall answer the questions set forth in Selling Shareholder Questionnaire (“Subscriber Questionnaire”) in the form attached as Exhibit F and deliver such completed Subscriber Questionnaire to the Company and Broker on or prior to the Closing Date. Seller represents that the information provided by such Seller shall be true and correct as of the Closing Date and the date such Subscriber Questionnaire is delivered to the Company and Broker.
Subscriber Questionnaire. I. The Subscriber represents and warrants that he or it comes within one category marked below, and that for any category marked, he or it has truthfully set forth, where applicable, the factual basis or reason the Subscriber comes within that category. ALL INFORMATION IN RESPONSE TO THIS SECTION WILL BE KEPT STRICTLY CONFIDENTIAL. The undersigned shall furnish any additional information which Purple Beverage Company, Inc. (the “Company”) deems necessary in order to verify the answers set forth below. Category A ___ The undersigned is an individual (not a partnership, corporation, etc.) whose individual net worth, or joint net worth with his or her spouse, presently exceeds $1,000,000.
Subscriber Questionnaire. In connection with the subscription for shares of Class A Common Stock (the "Common Stock") issued by Exodus Movement, Inc., a Delaware corporation (the "Company"), please complete this Subscriber Questionnaire. The offer and sale of the shares of Common Stock is being made by the Company and certain selling stockholders (the "Selling Stockholders") pursuant to an offering statement (the "Offering Circular") filed with the U.S. Securities and Exchange Commission pursuant to Regulation A ("Regulation A") under the Securities Act of 1933, as amended ("Securities Act"). The Company intends to use the net proceeds of this offering for the continued expansion of the Exodus platform, with a focus on software development, and increasing the Company’s marketing efforts to attract additional customers to the Exodus platform. The Company will not receive any proceeds from the sale of shares of Common Stock by the Selling Stockholders. The potential subscriber in the Common Stock shall be referred to in this Agreement as the "Subscriber." This Subscriber Questionnaire should be completed either by the Subscriber or, if the Subscriber is an entity, by an authorized representative of the Subscriber. The Subscriber Questionnaire and the Subscription Agreement are collectively referred to as the "Agreement." If the Subscriber Questionnaire indicates that any Subscriber’s response to a question requires further information, the Subscriber should contact the Company as soon as possible. Subscribers must complete and return all other additional required documentation, including an IRS Form W-9.
Subscriber Questionnaire. PERSONAL DATA. Full Name Residence Telephone (Area Code Number) Business Telephone (Area Code Number) Residence or Principal Address (Street/City/State/Zip Code) Birth Date Mailing Address (if other than residence) Citizenship (U.S./Other) Marital Status Social Security/Taxpayer I.D. Number Spouse’s Full Name E-mail Address Spouse’s Social Security Number Facsimile Number (Area Code/Number) ACCREDITED INVESTOR. If Subscriber (or the entity on behalf of which Subscriber is acting) is an “accredited investor” as that term is defined in Rule 501(a) of Regulation D promulgated under the Act, and, as such, falls within at least one of the following categories, then please INITIAL each applicable category.
Subscriber Questionnaire. Income $ USD Source of income Occupation Industry Education If retired, former occupation Employer Name No. of Years Employer Address Marital Status [_] S [_] M [_] D [_] DP [_] W Dependents [_] 0 [_] 1 [_] 2 [_] >2 Investment & Product Experience Current Portfolio Alternative Investments [_] None [_] < 2 years [_] 2 – 5 years [_] > 5 years $ Annuities [_] None [_] < 2 years [_] 2 – 5 years [_] > 5 years $ Bank CDs [_] None [_] < 2 years [_] 2 – 5 years [_] > 5 years $ Bonds [_] None [_] < 2 years [_] 2 – 5 years [_] > 5 years $ Cash or Cash Equivalent [_] None [_] < 2 years [_] 2 – 5 years [_] > 5 years $ Hedge Funds [_] None [_] < 2 years [_] 2 – 5 years [_] > 5 years $ Margin [_] None [_] < 2 years [_] 2 – 5 years [_] > 5 years $ Mutual Funds-Exchange Traded [_] None [_] < 2 years [_] 2 – 5 years [_] > 5 years $ Options [_] None [_] < 2 years [_] 2 – 5 years [_] > 5 years $ Private Placements [_] None [_] < 2 years [_] 2 – 5 years [_] > 5 years $ Real Estate [_] None [_] < 2 years [_] 2 – 5 years [_] > 5 years $ Stocks [_] None [_] < 2 years [_] 2 – 5 years [_] > 5 years $ Investable Asset [_] < $50,000 [_] $50,001 – $100,000 [_] $100,001 – $250,000 [_] $250,001 – $500,000 [_] $500,001 – $750,000 [_] $750,001 – $1,000,000 [_] $1,000,001 – $2,500,000 [_] $2,500,001 – $5,000,000 [_] $5,000,001 – $7,500,000 [_] $7,500,001 – $25,000,000 [_] > $25,000,001 Liquid Net Worth (excluding primary residence) [_] < $50,000 [_] $50,001 – $100,000 [_] $100,001 – $250,000 [_] $250,001 – $500,000 [_] $500,001 – $750,000 [_] $750,001 – $1,000,000 [_] $1,000,001 – $2,500,000 [_] $2,500,001 – $5,000,000 [_] $5,000,001 – $7,500,000 [_] $7,500,001 -$25,000,000 [_] >$25,000,001 Total Net Worth (excluding primary residence) [_] < $50,000 [_] $50,001 – $100,000 [_] $100,001 – $250,000 [_] $250,001 – $500,000 [_] $500,001 – $750,000 [_] $750,001 – $1,000,000 [_] $1,000,001 – $2,500,000 [_] $2,500,001 – $5,000,000 [_] $5,000,001 – $7,500,000 [_] $7,500,001 – $25,000,000 [_] >$25,000,001 Annual Expenses (recurring) [_] $50,000 and under [_] $50,001-100,000 $100,001-250,000 [_] $250,001-500,000 [_] > $500,000 Special Expenses (future, non-recurring) [_] None [_] $50,000 and under [_] $50,001-100,000 [_] $100,001-250,000 [_] > $250,000 Timeframe for Special Expenses [_] Within 1 year [_] 2 – 3 years [_] 3 – 5 years [_] 6 – 8 years [_] > 8 years [_] None or Never Investor Initial ________ _______ Are you or anyone with an interest in this account either: (1) a senior military, govern...
Subscriber Questionnaire. Review carefully, complete, and sign the Subscriber Questionnaire that is attached to the Subscription Agreement as Appendix 1. Each Subscriber (including joint owners) must answer all of the relevant questions set forth on the “Subscriber Questionnaire” and sign the questionnaire where indicated in Part C therein.
Subscriber Questionnaire. NeuroOne Medical Technologies Corporation 00000 Xxx Xxxxxx Xxxxx, Xxxxx 000 Xxxxxxxxxx, XX 00000 The information contained herein is being furnished to NeuroOne Medical Technologies Corporation (the “Company”) in order for the Company to determine whether the undersigned’s subscription for Convertible Promissory Notes (the “Notes”) and Warrants (the “Warrants”) therein may be accepted pursuant to Section 4(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”) and Regulation D promulgated thereunder (“Regulation D”). The undersigned understands that (i) the Company will rely upon the following information for purposes of complying with Federal and applicable state securities laws, (ii) none of the Notes, the Warrants or any securities issuable thereunder will be registered under the Securities Act in reliance upon the exemption from registration provided by Section 4(a)(2) of the Securities Act and Regulation D, and (iii) this questionnaire is not an offer to sell nor the solicitation of an offer to buy any Notes, Warrants or any other securities, to the undersigned. The following representations and information are furnished herewith:
