Telephone Number Telephone Number. Fax Number (if available) Fax Number (if available)
Telephone Number Telephone Number. Fax Number (if available) ________________________________ Fax Number (if available) _________________________________ E-Mail (if available) ________________________________ E-Mail (if available) __________________________________ (Signature) ________________________________ (Signature of Additional Purchaser) ACCEPTED this ___ day of _________ 2009, on behalf of the Company. By:_________________________________ Name: Title: EXECUTION BY SUBSCRIBER WHICH IS AN ENTITY (Corporation, Partnership, LLC, Trust, Etc.) _____________________________________________________________________________ Name of Entity (Please Print) Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) By: _________________________________ Name: Title: [seal] Attest: _________________________________ (If Entity is a Corporation) _________________________________ _________________________________ Address ACCEPTED this ____ day of __________ 2009, on behalf of the Company. By: _________________________________ Name: Title: President and Chief Executive Officer INVESTOR QUESTIONNAIRE Instructions: Check all boxes below which correctly describe you. o You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the “Securities Act”), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the “Exchange Act”), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the “Investment Company Act”), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) a Small Business Investment Company licensed by the U.S. Small Business Administration under Section 301 (c) or (d) of the Small Business Investment Act of 1958, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agen...
Telephone Number Telephone Number. Residence Street Address Residence Street Address City, State & Zip Code City, State & Zip Code Mailing Address (Only if different from residence address) Mailing Address (Only if different from residence address) City, State & Zip Code City, State & Zip Code Email address Email address Individual Subscriber Type of Ownership: The REG-CF SAFE subscribed for are to be registered in the following form of ownership: ❑ Individual Ownership ❑ Joint Tenants with Right of Survivorship (Note: If this type of ownership is selected, information and signature of sec- ond individual are required to be provided above). Briefly describe the relationship between the parties (e.g., married). ❑ Tenants in Common (Note: If this type of ownership is selected, information and signature of second individual are required to be provided above). Briefly describe the relationship between the parties (e.g., married).
Telephone Number Telephone Number. Fax Number (if available) Fax Number (if available) E-Mail (if available) E-Mail (if available) (Signature) (Signature of Additional Subscriber) ACCEPTED this day of 2016, on behalf of Madyson Equity Group, LP. By: Name: Title: EXECUTION BY SUBSCRIBER WHICH IS AN ENTITY (Corporation, Partnership, Trust, Etc.) Name of Entity (Please Print) Date of Incorporation or Organization: State of Principal Office: Federal Taxpayer Identification Number: ____________________________________________________ Office Address City, State and Zip Code Telephone Number Fax Number (if available) E-Mail (if available) [seal] By: Attest: _____________________ Name: (If Entity is a Corporation) Title: * If Subscriber is a Registered Representative with a FINRA member firm, have the following acknowledgement signed by the appropriate party: The undersigned FINRA member firm acknowledges receipt of the notice required by Rule 3050 of the FINRA Conduct Rules ACCEPTED this day of 2016, on behalf of Madyson Equity Group, LP. Name of FINRA Firm By: By: Name: Name: Title: Title: INVESTOR QUESTIONNAIRE Instructions: Check all boxes below which correctly describe you. ¨ You are (i) a bank, as defined in Section 3(a)(2) of the Securities Act of 1933, as amended (the "Securities Act"), (ii) a savings and loan association or other institution, as defined in Section 3(a)(5)(A) of the Securities Act, whether acting in an individual or fiduciary capacity, (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended (the "Exchange Act"), (iv) an insurance company as defined in Section 2(13) of the Securities Act, (v) an investment company registered under the Investment Company Act of 1940, as amended (the "Investment Company Act"), (vi) a business development company as defined in Section 2(a)(48) of the Investment Company Act, (vii) a Small Business Investment Company licensed by the U.S. Small Business Administration under Section 301 (c) or (d) of the Small Business Investment Act of 1958, as amended, (viii) a plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions, for the benefit of its employees and you have total assets in excess of $5,000,000, or (ix) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, as amended ("ERISA") and (1) the decision that you shall subscribe for and purchase Interests (the "In...
Telephone Number Telephone Number. Facsimile Number Facsimile Number ----------------------------------------- SWIFT Number ----------------------------------------- Telex Number FUNDS TRANSFER ADDENDUM [STATE STREET LOGO] INSTRUCTION(S) TELEPHONE CONFIRMATION Fund________________________________________ Investment Adviser__________________________ Authorized Initiators Please Type or Print Please provide a listing of Fund officers or other individuals are currently authorized to initiate wire transfer instructions to State Street: NAME TITLE (Specify whether position SPECIMEN SIGNATURE is with Fund or Investment Adviser) ------------------------- ------------------------------ --------------------------- ------------------------- ------------------------------ --------------------------- ------------------------- ------------------------------ --------------------------- ------------------------- ------------------------------ --------------------------- ------------------------- ------------------------------ --------------------------- Authorized Verifiers Please Type or Print Please provide a listing of Fund officers of other individuals who will be CALLED BACK to verify the initiation of repetitive wires of $10 million or more and all non repetitive wire instructions: NAME CALLBACK PHONE NUMBER DOLLAR LIMITATION (IF ANY) ------------------------- ------------------------------ --------------------------- ------------------------- ------------------------------ --------------------------- ------------------------- ------------------------------ --------------------------- ------------------------- ------------------------------ --------------------------- ------------------------- ------------------------------ --------------------------- STATE STREET SCHEDULE A GLOBAL CUSTODY NETWORK SUBCUSTODIANS Country Subcustodian Argentina Citibank, N.A. Australia Westpac Banking Corporation Austria Erste Bank der Osterreichischen Sparkassen AG Bahrain HSBC Bank Middle East (as delegate of The Hongkong and Shanghai Banking Corporation Limited) Bangladesh Standard Chartered Bank Belgium Fortis Bank nv-sa Bermuda The Bank of Bermuda Limited Bolivia Citibank, N. A. Botswana Barclays Bank of Botswana Limited Brazil Citibank, N.A. Bulgaria ING Bank N.V. Canada State Street Trust Company Canada Chile BankBoston, N.A. People's Republic The Hongkong and Shanghai of China Banking Corporation Limited, Shanghai and Shenzhen branches Colombia Cititrust Colombia S.A. Sociedad Fiduciaria
Telephone Number Telephone Number. Social Security Number/EIN Social Security Number Date Date * * * * * TRIPLEPULSE INC. This Subscription is accepted By: Name: on _________________, 202_ Title: APPENDIX A An accredited investor includes the following categories of investor:
Telephone Number Telephone Number. Fax Number (if available) Fax Number (if available) E-Mail (if available) E-Mail (if available) (Signature) (Signature of Additional Subscriber) EXECUTION BY SUBSCRIBER WHICH IS AN ENTITY (Corporation, Partnership, Trust, Etc.) ____________________________________________________________________________ Name of Entity (Please Print) Date of Incorporation or Organization: _________________________________________ State of Principal Office: ____________________________________________________ Federal Taxpayer Identification Number: ________________________________________ ____________________________________________ Office Address ____________________________________________ City, State and Zip Code ____________________________________________ Telephone Number ____________________________________________ Fax Number (if available) ____________________________________________ E-Mail (if available) [seal] By: _____________________________ Name: Title: Attest: ____________________________ (If Entity is a Corporation) *If Subscriber is a Registered Representative with a FINRA member firm, have the following acknowledgement signed by the appropriate party: The undersigned FINRA member firm acknowledges receipt of the notice required by Rule 3050 of the FINRA Conduct Rules ____________________________ Name of FINRA Firm By: ________________________ Name: Title: COMPANY: DEERFIELD RESOURCES, LTD. By: _______________________________ Name: Xxxxxxxx Xxx Title: Chief Executive Officer
Telephone Number Telephone Number. Social Security Number/EIN Social Security Number Date Date * * * * * This Subscription is accepted XTI Aircraft Company on _____________, 2015 By: Name: Title: APPENDIX A An accredited investor includes the following categories of investor:
Telephone Number Telephone Number. Facsimile Number Facsimile Number ------------------------------ SWIFT Number ------------------------------ Telex Number [GRAPHIC OMITTED]
Telephone Number Telephone Number. Fax Number (if available) Fax Number (if available) E-Mail (if available) E-Mail (if available) (Signature) (Signature of Additional Subscriber) Title (if applicable) Title (if applicable) ACCEPTED __________________________, on behalf Gratus Capital Properties Fund III LLC By: Name: Title:
