Additional Subscriber Information. The subscriber, named above, certifies the following under penalties of perjury:
Additional Subscriber Information. Iroquois Valley requires information for all natural persons associated with the investment. Please complete the following information for all natural persons associated with, or benefitting from, the investment. ADDITIONAL PERSON ONE Name:________________________________ Social Security Number:____ Address:_______________________________________________________ Phone:____________________________ Email:_______________________ Date of Birth:______________________ Citizenship: __________________ Include as Investment Contact with access to online investor portal? ❑ YES ❑ NO ADDITIONAL PERSON TWO Name:________________________________ Social Security Number:____ Address:_______________________________________________________ Phone:____________________________ Email:_______________________ Date of Birth:______________________ Citizenship: __________________ Include as Investment Contact with access to online investor portal? ❑ YES ❑ NO ADDITIONAL PERSON THREE Name:________________________________ Social Security Number:____ Address:_______________________________________________________ Phone:____________________________ Email:_______________________ Date of Birth:______________________ Citizenship: __________________ Include as Investment Contact with access to online investor portal? ❑ YES ❑ NO ADDITIONAL PERSON FOUR Name:________________________________ Social Security Number:____ Address:_______________________________________________________ Phone:____________________________ Email:_______________________ Date of Birth:______________________ Citizenship: __________________ Include as Investment Contact with access to online investor portal? ❑ YES ❑ NO
Additional Subscriber Information. MUST BE COMPLETED The Subscriber holds, directly or indirectly, or exercises control over, the following securities of the Issuer (prior to the Offering (as defined herein)): ___________________ The Subscriber (circle one) is or is not a Registrant (as defined herein). The Subscriber (circle one) is or is not an Insider (as defined herein) of the Issuer.
Additional Subscriber Information. DECLARATIONS
Additional Subscriber Information. The Subscriber further represents and warrants that the following information is true and complete: Name of Subscriber: Date of Birth: Name of Joint Subscriber, if any: Date of Birth: Amount of Initial Capital Contribution: $ Subscriber’s Social Security or Taxpayer ID No.: (A Subscriber who does not have a Social Security or Taxpayer ID number will not be admitted to the Partnership, unless the General Partner expressly waives such requirement.) Type of owner or form of ownership: Individual Joint Tenants With Right of Survivorship IRA Partnership Tenants in Common Xxxxx Plan Corporation Employee Benefit Plan Other Trust Limited Liability Company Specify: Address (Principal State of Residence): Mailing Address, if different: Telephone number: Fax number: Email: Name of Remitting Bank: Address: SWIFT/ABA/CHIPS/UID: Account name: Account number: Under Reference: Value Date for Capital Contribution: Unless notified otherwise, the Partnership will use the foregoing bank account details in the case of withdrawals. If the Subscriber is a corporation, limited liability company, partnership or a trust, please provide the names and addresses of the officers, directors, partners, managers, members and principal beneficiaries, as the case may be. To the extent the context permits, all of the information in this questionnaire is furnished on behalf of and is applicable to each of the persons listed below. The General Partner may require any one of these individuals to complete a separate Investor Questionnaire.
Additional Subscriber Information. The Subscriber understands that the information provided in this Agreement (including the Exhibits hereto and any other documents provided by the Subscriber to the Company or the Adviser in connection with its investment in the Company) or pursuant to this Agreement will be relied upon by the Company and the Adviser, including for the purposes of (i) determining the eligibility of the Subscriber to purchase or hold the Shares, (ii) making any required filings pursuant to Applicable Securities Laws and the Investment Advisers Act of 1940, as amended (the "Advisers Act"), (iii) determining the Company's eligibility to invest in prospective portfolio companies and (iv) making representations in connection with the Company's investments. The Subscriber shall cooperate with the Adviser and agrees to provide in a timely manner, if requested, any additional information, form, disclosure, certification or documentation that the Adviser may reasonably request (including any information requested pursuant to the Foreign Account Reporting Regimes (as defined below)) in order to determine the eligibility of the Subscriber to purchase or hold the Shares, for the purpose of making any required filings pursuant to Applicable Securities Laws or the Advisers Act, for the purpose of determining the Company's eligibility to invest in prospective portfolio companies for the purpose of providing any necessary notice to, or obtaining any necessary approval or consent from, any governmental authority related to the Company's investments in a portfolio company, or for the purpose of making representations in connection with the Company's investments in portfolio investments, or in order to maintain appropriate records and provide for withholding amounts, if any, relating to the Subscriber's Shares, or otherwise as the Adviser deems reasonably necessary for the conduct of the Company's affairs and/or in order for the Company to comply with any of the Foreign Account Reporting Regimes. The Subscriber will furnish promptly to the Company, upon request, any information about the Subscriber reasonably determined by the Adviser to be necessary or convenient for the formation, operation, dissolution, winding-up or termination of the Company, including, if relevant, information with respect to the foreign citizenship, residency, ownership or control of the Subscriber and its beneficial owners so as to permit the Adviser to evaluate and comply with any regulatory and tax requirements appl...
Additional Subscriber Information. Account Reference (if applicable): 1. Number and kind of securities of the Issuer held, directly or indirectly, if any: By: Authorized Signature 2. State whether Subscriber is an Insider of the Issuer: Yes ☐ No ☐ (Official Capacity or Title – if the Subscriber is not an individual) (Name of individual whose signature appears above if different than the name of the Subscriber printed above.) Name of Principal (Subscriber’s Address, including Municipality and Province) Principal's Address City/Town Province Postal Code (Telephone Number) (Email Address) Principal's Telephone Number -OR- E-mail Address
Additional Subscriber Information. Iroquois Valley requires information for all natural persons associated with the investment. Please complete the following information for all natural persons associated with, or benefitting from, the investment. ADDITIONAL PERSON ONE Name:________________________________ Social Security Number:____ Address:_______________________________________________________ Phone:____________________________ Email:_______________________ Date of Birth:______________________ Citizenship: __________________ Include as Investment Contact with access to online investor portal? ❑ YES ❑ NO ADDITIONAL PERSON TWO Name:________________________________ Social Security Number:____ Address:_______________________________________________________ Phone:____________________________ Email:_______________________ Date of Birth:______________________ Citizenship: __________________ Include as Investment Contact with access to online investor portal? ❑ YES ❑ NO
Additional Subscriber Information. 1. Number and kind of securities of the Issuer held, directly or indirectly, if any: 2. State whether Subscriber is an Insider of the Issuer: Yes No Subscriber Information: (Name of Subscriber) Account Reference (if applicable): By: Authorized Signature (Official Capacity or Title – if the Subscriber is not an individual) (Name of individual whose signature appears above if different than the name of the Subscriber printed above.) (Subscriber’s Address, including Municipality and Province) (Telephone Number) (Email Address) If the Subscriber is signing as agent for a principal and is not deemed to be purchasing as principal pursuant to NI 45-106 (as defined herein) by virtue of being either: (i) a trust company or trust corporation acting on behalf of a fully managed account managed by the trust company or trust corporation, as the case may be; or (ii) a person acting on behalf of a fully managed account managed by it, and in each case satisfying the criteria set forth in NI 45-106, complete the following and ensure that Schedule B, if applicable, is completed in respect of such principal: Name of Principal Principal's Address City/Town Province Postal Code Principal's Telephone Number -OR- E-mail Address ACCEPTANCE: The Corporation hereby accepts the subscription as set forth above on the terms and conditions contained in this Subscription this day of , 202[●]. 2455350 ONTARIO INC. O/A BARON AUTO GROUP Per: Authorized Signatory TERMS AND CONDITIONS OF SUBSCRIPTION FOR PROMISSORY NOTE
Additional Subscriber Information. Account Reference (if applicable):____________________ 1. Number and kind of securities of the Issuer held, directly or indirectly, if any: By: Authorized Signature
