Common use of Background Information Clause in Contracts

Background Information. Name of Beneficial Owner of the Shares:____________________________________________________________ Business Address:_______________________________________________________________________________ (Number and Street) ______________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) _________________________________________________________________________ Type of entity:__________________________________________________________________________________ Were you formed for the purpose of investing in the securities being offered? Yes ____ No ____ If an individual: Residence Address:______________________________________________________________________________ (Number and Street) ______________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) _________________________________________________________________________ Age:­­­­­­­­ ­__________ Citizenship: ____________ Where registered to vote: _______________ If an individual, set forth in the space provided below the state in the United States in which you maintain your residence: If an entity, set forth in the space provided below the state in the United States in which you made your investment decision: Are you a director or executive officer of the Company? Yes ____ No ____ Social Security or Taxpayer Identification No._________________________________________________________

Background Information. Name of Beneficial Owner of the SharesSecurities:____________________________________________________________ Business Address:_______________________________________________________________________________ (Number and Street) ______________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) _________________________________________________________________________ Type of entity:__________________________________________________________________ State of formation:______________________ Approximate Date of formation: ____________________ Were you formed for the purpose of investing in the securities being offered? Yes ____ No ____ If an individual: Residence Address:______________________________________________________________________________ (Number and Street) ______________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) _________________________________________________________________________ Age:­­­­­­­­ ­Age: __________ Citizenship: ____________ Where registered to vote: _______________ If an individual, set Set forth in the space provided below the state state(s), if any, in the United States in which you maintain maintained your residence: If an entity, set forth in residence during the space provided below past two years and the state in the United States in dates during which you made your investment decisionresided in each state: Are you a director or executive officer of the CompanyCorporation? Yes ____ No ____ Social Security or Taxpayer Identification No._________________________________________________________

Background Information. Name of Beneficial Owner of the Shares:Securities: _____________________________________________________________________________ Business Address:__________________________________________________________________________________________________ (Number and Street) _______________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) ____________________________________________________________________________________________ If a corporation, partnership, limited liability company, trust or other entity: Type of entity: _________________________________________________ State of formation:______________________ Approximate Date of formation: ____________________ Were you formed for the purpose of investing in the securities being offered? Yes ____ No ____ If an individual: Residence Address: ________________________________________________________________________________________________ (Number and Street) ________________________________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) _________________________________________________________________________ Type of entity:__________________________________________________________________________________ Were you formed for the purpose of investing in the securities being offered? Yes ____ No ____ If an individualAge: Residence Address:______________________________________________________________________________ (Number and Street) ______________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) _________________________________________________________________________ Age:­­­­­­­­ ­__________ Citizenship: ____________ Where registered to vote: _______________ If an individual, set Set forth in the space provided below the state state(s), if any, in the United States in which you maintain maintained your residence: If an entity, set forth in residence during the space provided below past two years and the state in the United States in dates during which you made your investment decisionresided in each state: Are you a director or executive officer of the CompanyCorporation? Yes ____ No ____ Social Security or Taxpayer Identification No.. _________________________________________________________

Background Information. Name of Beneficial Owner of the Shares:____________________________________________________________ Securities: Business Address:_______________________________________________________________________________ (Number and Street) City: _________________ State: _____ Zip Code: ___________ Telephone Number: ______________________________________________________________________ If a corporation, partnership, limited liability company, trust or other entity: Type of entity: _________________________ (City) (State) (Zip Code) Telephone NumberState of formation: (___) _________________________________________________________________________ Type Approximate Date of entity:________________________________________________________________formation: __________________ Were you formed for the purpose of investing in the securities being offered? Yes ____ o No ____ If an individual: o Residence Address:___________: ___________________________________________________________________ (Number and Street) City: _________________ State: _____ Zip Code: ________________________________________________________ Telephone Number: _______________________ (City) (State) (Zip Code) Telephone NumberAge: (___) _________________________________________________________________________ Age:­­­­­­­­ ­__________ Citizenship: ____________ Where registered to vote: _______________ If an individual, set Set forth in the space provided below the state state(s), if any, in the United States in which you maintain maintained your residence: If an entity, set forth in residence during the space provided below past two years and the state in the United States in dates during which you made your investment decisionresided in each state: Are you a director or executive officer of the CompanyCorporation? Yes ____ No ____ Social Security or Taxpayer Identification No.: _________________________________________________________

Background Information. Name of Beneficial Owner of the Shares:Securities: _______________________________________________________________ Business Address:: ___________________________________________________________________________________ (Number and Street) __________________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) )_____________________________________________________________________________ Type of entity:: _____________________________________________________________________________________ State of formation:______________________ Approximate Date of formation: __________________________________ Were you formed for the purpose of investing in the securities being offered? Yes ____ No ____ If an individual: Residence Address:: __________________________________________________________________________________ (Number and Street) __________________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) )______________________________________________________________________________ Age:­­­­­­­­ ­Age: __________ Citizenship: ____________ Where registered to vote: _______________ If an individual, set Set forth in the space provided below the state state(s), if any, in the United States in which you maintain maintained your residence: If an entity, set forth in residence during the space provided below past two years and the state in the United States in dates during which you made your investment decisionresided in each state: Are you a director or executive officer of the CompanyCorporation? Yes ____ No ____ Social Security or Taxpayer Identification No.. ______________________________________________________________

Background Information. Name of Beneficial Owner of the Shares:____________________________________________________________ Securities: Business Address:_______________________________________________________________________________ (Number and Street) City: _________________ State: _____ Zip Code: ___________ Telephone Number: ______________________________________________________________________ If a corporation, partnership, limited liability company, trust or other entity: Type of entity: _________________________ (City) (State) (Zip Code) Telephone NumberState of formation: (___) _________________________________________________________________________ Type Approximate Date of entity:________________________________________________________________formation: __________________ Were you formed for the purpose of investing in the securities being offered? Yes ____ No ____ If an individual: Residence Address:___________: ___________________________________________________________________ (Number and Street) City: _________________ State: _____ Zip Code: ________________________________________________________ Telephone Number: _______________________ (City) (State) (Zip Code) Telephone NumberAge: (___) _________________________________________________________________________ Age:­­­­­­­­ ­__________ Citizenship: ____________ Where registered to vote: _______________ If an individual, set Set forth in the space provided below the state state(s), if any, in the United States in which you maintain maintained your residence: If an entity, set forth in residence during the space provided below past two years and the state in the United States in dates during which you made your investment decisionresided in each state: Are you a director or executive officer of the CompanyCorporation? Yes ____ No ____ Social Security or Taxpayer Identification No.: _________________________________________________________

Background Information. Name of Beneficial Owner of the Shares:____________________________________________________________ Securities: Business Address:_______________________________________________________________________________ (Number and Street) City: _________________ State: _____ Zip Code: ___________ Telephone Number: ______________________________________________________________________ If a corporation, partnership, limited liability company, trust or other entity: Type of entity: _________________________ (City) (State) (Zip Code) Telephone NumberState of formation: (___) _________________________________________________________________________ Type Approximate Date of entity:________________________________________________________________formation: __________________ Were you formed for the purpose of investing in the securities being offered? Yes ____ o No ____ o If an individual: Residence Address:___________: ___________________________________________________________________ (Number and Street) City: _________________ State: _____ Zip Code: ________________________________________________________ Telephone Number: _______________________ (City) (State) (Zip Code) Telephone NumberAge: (___) _________________________________________________________________________ Age:­­­­­­­­ ­__________ Citizenship: ____________ Where registered to vote: _______________ If an individual, set Set forth in the space provided below the state state(s), if any, in the United States in which you maintain maintained your residence: If an entity, set forth in residence during the space provided below past two years and the state in the United States in dates during which you made your investment decisionresided in each state: Are you a director or executive officer of the CompanyCorporation? Yes ____ o No ____ o Social Security or Taxpayer Identification No.: _________________________________________________________

Background Information. Name of Beneficial Owner of the SharesSecurities:____________________________________________________________ Business Address:_______________________________________________________________________________ (Number and Street) ______________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) _________________________________________________________________________ Type of entity:__________________________________________________________________ State of formation:______________________ Approximate Date of formation: ____________________ Were you formed for the purpose of investing in the securities being offered? Yes ____ No ____ If an individual: Residence Address:______________________________________________________________________________ (Number and Street) ______________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) _________________________________________________________________________ Age:­­­­­­­­ ­Age: __________ Citizenship: ____________ Where registered to vote: _______________ If an individual, set Set forth in the space provided below the state state(s), if any, in the United States in which you maintain maintained your residence: If an entity, set forth in residence during the space provided below past two years and the state in the United States in dates during which you made your investment decisionresided in each state: Are you a director or executive officer of the CompanyCorporation? Yes ____ No ____ Social Security or Taxpayer Identification No._________________________________________________________

Background Information. Name of Beneficial Owner of the Shares:: __________________________________________________________________ Business Address:: _________________________________________________________________________________________________________ (Number and Street) ______________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) ______________________________________________________________________________________________ Type of entity:: ____________________________________________________________________________________________________________ Were you formed for the purpose of investing in the securities being offered? Yes _____ No _____ If an individual: Residence Address:: ___________________________________________________________________________________________________ (Number and Street) ______________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) _________________________________________________________________________ Age:­­­­­­­­ ­_________________ Age:______ Citizenship: ____________________________ Where registered to vote: __________________________________________ If an individual, set forth in the space provided below the state in the United States in which you maintain your residence: If an entity, set forth in the space provided below the state in the United States in which you made your investment decision: Are you a director or executive officer of the Company? Yes _____ No _____ Social Security or Taxpayer Identification No.: _________________________________________________________

Background Information. Name of Beneficial Owner of the Shares:____________________________________________________________ Securities: Business Address:_______________________________________________________________________________ (Number and Street) City: _________________ State: _____ Zip Code: ___________ Telephone Number: ______________________________________________________________________ If a corporation, partnership, limited liability company, trust or other entity: Type of entity: _________________________ (City) (State) (Zip Code) Telephone NumberState of formation: (___) _________________________________________________________________________ Type Approximate Date of entity:________________________________________________________________formation: __________________ Were you formed for the purpose of investing in the securities being offered? Yes ____ ☐ No ____ ☐ If an individual: Residence Address:___________: ___________________________________________________________________ (Number and Street) City: _________________ State: _____ Zip Code: ________________________________________________________ Telephone Number: _______________________ (City) (State) (Zip Code) Telephone NumberAge: (___) _________________________________________________________________________ Age:­­­­­­­­ ­__________ Citizenship: ____________ Where registered to vote: _______________ If an individual, set Set forth in the space provided below the state state(s), if any, in the United States in which you maintain maintained your residence: If an entity, set forth in residence during the space provided below past two years and the state in the United States in dates during which you made your investment decisionresided in each state: Are you a director or executive officer of the CompanyCorporation? Yes ____ ☐No ____ ☐ Social Security or Taxpayer Identification No.: _________________________________________________________

Background Information. Name of Beneficial Owner of the Shares:___________Securities: _________________________________________________ Business Address:: __________________________________________________________________________________ (Number and Street) __________________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) _________________________________________________________________________ Type of entity:: _________________________________________________ State of formation:______________________ Approximate Date of formation: ____________________ Were you formed for the purpose of investing in the securities being offered? Yes ____ No ____ If an individual: Residence Address:: __________________________________________________________________________________ (Number and Street) __________________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) _________________________________________________________________________ Age:­­­­­­­­ ­__________ Citizenship: ____________ Where registered to vote: _______________ If an individual, set Set forth in the space provided below the state state(s), if any, in the United States in which you maintain maintained your residence: If an entity, set forth in residence during the space provided below past two years and the state in the United States in dates during which you made your investment decisionresided in each state: Are you a director or executive officer of the CompanyCorporation? Yes ____ No ____ Social Security or Taxpayer Identification No.. _________________________________________________________

Background Information. Name of Beneficial Owner of the SharesSecurities:____________________________________________________________ Business Address:_______________________________________________________________________________ (Number and Street) ______________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___)__________________________________________________________ Type of entity:___________________________________________________________________ State of formation:______________________ Approximate Date of formation: ____________________ Were you formed for the purpose of investing in the securities being offered? Yes ¨ No ¨ If an individual: Residence Address:_______________________________________________________________ (Number and Street) ______________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) __________________________________________________________ Age: __________ Citizenship: ____________ Where registered to vote: _______________ Type Set forth in the space provided below the state(s), if any, in the United States in which you maintained your residence during the past two years and the dates during which you resided in each state: Are you a director or executive officer of entity:the Corporation? Yes ¨ No ¨ Social Security or Taxpayer Identification No. __________________________________________________________________________________ Were you formed for the purpose of investing in the securities being offered? Yes ____ No ____ If an individual: Residence Address:______________________________________________________________________________ (Number and Street) ______________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) _________________________________________________________________________ Age:­­­­­­­­ ­__________ Citizenship: ____________ Where registered to vote: _______________ If an individual, set forth in the space provided below the state in the United States in which you maintain your residence: If an entity, set forth in the space provided below the state in the United States in which you made your investment decision: Are you a director or executive officer of the Company? Yes ____ No ____ Social Security or Taxpayer Identification No._________________________________________________________

Background Information. Name of Beneficial Owner of the Shares:ADSs: ________________________________________________________________________ Business Address:: __________________________________________________________________________________________ (Number and Street) ____________________________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) ____________________________________________________________________________________ Type of entity:: _____________________________________________________________________________________________ State of formation:______________________ Approximate Date of formation: ____________________ Were you formed for the purpose of investing in the securities being offered? Yes ____ No ____ If an individual: Residence Address:: _________________________________________________________________________________________ (Number and Street) ___________________________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) ____________________________________________________________________________________ Age:­­­­­­­­ ­Age: __________ Citizenship: ____________ Where registered to vote: _______________ If an individual, set Set forth in the space provided below the state state(s), if any, in the United States in which you maintain maintained your residence: If an entity, set forth in residence during the space provided below past two years and the state in the United States in dates during which you made your investment decisionresided in each state: Are you a director or executive officer of the Company? Yes ____ No ____ Social Security or Taxpayer Identification No.. _____________________________________________________________________

Background Information. Name of Beneficial Owner of the Shares:___: _________________________________________________________ Business Address:____: ___________________________________________________________________________ (Number and Street) ______________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) _________________________________________________________________________ Type of entity:____: ______________________________________________________________________________ Were you formed for the purpose of investing in the securities being offered? Yes ____ No ____ If an individual: Residence Address:____: __________________________________________________________________________ (Number and Street) ______________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) _________________________________________________________________________ Age:­­­­­­­­ ­Age:__________ Citizenship: ____________ Where registered to vote: _______________ If an individual, set forth in the space provided below the state in the United States in which you maintain your residence: If an entity, set forth in the space provided below the state in the United States in which you made your investment decision: Are you a director or executive officer of the Company? Yes ____ No ____ Social Security or Taxpayer Identification No.. _________________________________________________________

Background Information. Name of Beneficial Owner of the Shares:____________________________________________________________ Business AddressSecurities:_______________________________________________________________________________ (Number and Street) ______Business Address: ________________________________________________________________________________________ (Number and Street) (City) (State) (Zip Code) Telephone Number: (( ) ___) _______________________________________________________________________________ Type of entity:_____________________________________________________________________________________________ State of formation: ____________________ Approximate Date of formation:_______________________ Were you formed for the purpose of investing in the securities being offered? Yes ____ No ____ If an individual: Residence Address:_________________________________________________________________________________________ (Number and Street) (City) (State) (Zip Code) Telephone Number: ( ) ______________________________________________________________________________________________ (City) (State) (Zip Code) Telephone NumberAge: (___) _________________________________________________________________________ Age:­­­­­­­­ ­__________ Citizenship: ____________ Where registered to vote: _______________ If an individual, set Set forth in the space provided below the state state(s), if any, in the United States in which you maintain maintained your residence: If an entity, set forth in residence during the space provided below past two years and the state in the United States in dates during which you made your investment decisionresided in each state: Are you a director or executive officer of the CompanyCorporation? Yes ____ No ____ Social Security or Taxpayer Identification No._______________________________________________________________________

Background Information. Name of Beneficial Owner of the Shares:____________________________________________________________ Business Address:_______________________________________________________________________________ (Number and Street) ______________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) _________________________________________________________________________ Type of entity:__________________________________________________________________________________ Were you formed for the purpose of investing in the securities being offered? Yes ____ No ____ If an individual: Residence Address:______________________________________________________________________________ (Number and Street) ______________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) ___________________)______________________________________________________ Age:­­­­­­­­ ­Age: _____________ Citizenship: ____________ Where registered to vote: _______:________ If an individual, set forth in the space provided below the state in the United States in which you maintain your residence: If an entity, set forth in the space provided below the state in the United States in which you made your investment decision: Are you a director or executive officer of the Company? Yes ____ No ____ Social Security or Taxpayer Identification No._________________________________________________________

Background Information. Name of Beneficial Owner of the Shares:____________________Securities: ________________________________________ Business Address:__________________: _____________________________________________________________ (Number and Street) ______________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (_____) _____________________________________________________ If a corporation, partnership, limited liability company, trust or other entity: Type of entity: ________________________________________________________________ Type State of entity:_____________________formation: _____________________________________________________________ Approximate Date of formation: __________________________________________________ Were you formed for the purpose of investing in the securities Securities being offered? Yes ____ No ____ If an individual: Residence Address:__________________: ____________________________________________________________ (Number and Street) ______________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (_____) _________________________________________________________________________ Age:­­­­­­­­ ­__Age: ________ Citizenship: ____________ Where registered to vote: _______________ If an individual, set Set forth in the space provided below the state state(s), if any, in the United States in which you maintain maintained your residence: If an entity, set forth in residence during the space provided below past two years and the state in the United States in dates during which you made your investment decisionresided in each state: Are you a director or executive officer of the CompanyCorporation? Yes ____ No ____ Social Security or Taxpayer Identification No.. _________________________________________________________

Background Information. Name of Beneficial Owner of the Shares:____________________________________________________________ Securities: Business Address:_______________________________________________________________________________ (Number and Street) City: _________________ State: ___________ Zip Code: ___________ Telephone Number: ______________________________________________________________________ US_ACTIVE\122682223\V-9 Type of entity: _________________________ (City) (State) (Zip Code) Telephone NumberState of formation: (___) _________________________________________________________________________ Type Approximate Date of entity:________________________________________________________________formation: __________________ Were you formed for the purpose of investing in the securities Securities being offered? Yes ____  No ____ If an individual:  Residence Address:_________________________: _____________________________________________________ (Number and Street) City: _________________ State: _________ Zip Code: ___________ Telephone Number: _______________________ Age: __________ Citizenship: _________ Where registered to vote: _______ Set forth in the space provided below the state(s), if any, in the United States in which you maintained your residence during the past two years and the dates during which you resided in each state: __________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) _________________________________________________________________________ Age:­­­­­­­­ ­__________ Citizenship: ____________ Where registered to voteAre you a director or executive officer of the Corporation? Yes  No  Social Security or Taxpayer Identification No.: _______________ If an individual, set forth in the space provided below the state in the United States in which you maintain your residence: If an entity, set forth in the space provided below the state in the United States in which you made your investment decision: Are you a director or executive officer of the Company? Yes ____ No ____ Social Security or Taxpayer Identification No._________________________________________________________US_ACTIVE\122682223\V-9

Background Information. Name of Beneficial Owner of the Shares:____________________________________________________________ Business Address:_____ADSs: __________________________________________________________________________ (Number and Street) ___Business Address: ___________________________________________________________________________________________ (Number and Street) (City) (State) (Zip Code) Telephone Number: (___) ______________________________________________________________________________________ Type of entity:: ___________________________________________________________________________________________ State of formation:______________________ Approximate date of formation: ____________________ Were you formed for the purpose of investing in the securities being offered? Yes ____ No ____ If an individual: Residence Address:______________________________________________________________________________ (Number and Street) ___: ___________________________________________________________________________________________ (Number and Street) (City) (State) (Zip Code) Telephone Number: (___) ______________________________________________________________________________________ Age:­­­­­­­­ ­Age: __________ Citizenship: ____________ Where registered to vote: _______________ If an individual, set Set forth in the space provided below the state state(s), if any, in the United States in which you maintain maintained your residence: If an entity, set forth in residence during the space provided below past two years and the state in the United States in dates during which you made your investment decisionresided in each state: Are you a director or executive officer of the Company? Yes ____ No ____ Social Security or Taxpayer Identification No.. ______________________________________________________________________

Background Information. Name of Beneficial Owner of the SharesSecurities:____________________________________________________________ Business Address:_______________________________________________________________________________ (Number and Street) ______________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___)__________________________________________________________ Type of entity:___________________________________________________________________ State of formation:______________________ Approximate Date of formation: ____________________ Were you formed for the purpose of investing in the securities being offered? Yes ____ No ____ If an individual: Residence Address:_______________________________________________________________ (Number and Street) ______________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) __________________________________________________________ Age: __________ Citizenship: ____________ Where registered to vote: _______________ Type Set forth in the space provided below the state(s), if any, in the United States in which you maintained your residence during the past two years and the dates during which you resided in each state: Are you a director or executive officer of entity:the Corporation? Yes ____ No ____ Social Security or Taxpayer Identification No. __________________________________________________________________________________ Were you formed for the purpose of investing in the securities being offered? Yes ____ No ____ If an individual: Residence Address:______________________________________________________________________________ (Number and Street) ______________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) _________________________________________________________________________ Age:­­­­­­­­ ­__________ Citizenship: ____________ Where registered to vote: _______________ If an individual, set forth in the space provided below the state in the United States in which you maintain your residence: If an entity, set forth in the space provided below the state in the United States in which you made your investment decision: Are you a director or executive officer of the Company? Yes ____ No ____ Social Security or Taxpayer Identification No._________________________________________________________

Background Information. Name of Beneficial Owner of the Preferred Shares:: ______________________________________________ Business Address: ________________________________________________________________________ Business Address:(Number and Street) ________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) ______________________________________ Type of entity: ______________________________________________ Were you formed for the purpose of investing in the securities being offered? Yes ____ No ____ Social Security or Taxpayer Identification No. _____________________ If an individual: Residence Address: _________________________________________________________________________ (Number and Street) ______________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) ___________________________________ Age:__________ Citizenship: ____________ Where registered to vote: _______________ Set forth in the space provided below the state(s), if any, in the United States in which you maintained your residence during the past two years and the dates during which you resided in each state: Are you a director or executive officer of the Company? Yes ____ No ____ Social Security or Taxpayer Identification No. _________________________________________________________________________ Type of entity:__________________________________________________________________________________ Were you formed for the purpose of investing in the securities being offered? Yes ____ No ____ If an individual: Residence Address:______________________________________________________________________________ (Number and Street) ______________________________________________________________________________________________ (City) (State) (Zip Code) Telephone Number: (___) _________________________________________________________________________ Age:­­­­­­­­ ­__________ Citizenship: ____________ Where registered to vote: _______________ If an individual, set forth in the space provided below the state in the United States in which you maintain your residence: If an entity, set forth in the space provided below the state in the United States in which you made your investment decision: Are you a director or executive officer of the Company? Yes ____ No ____ Social Security or Taxpayer Identification No._________________________________________________________

Background Information. Name of Beneficial Owner of the Shares:___________Securities: _________________________________________________ Business Address:_______________________________________________________________________________ (Number and Street) _____________________________________________________________________________City: _________________ (City) (State) (Zip Code) Telephone Number: (___) __ Zip Code: ___________________________________________________ Telephone Number: _______________________ Type of entity:: _________________________ Country/State of formation: _________________________________________ Approximate Date of formation: __________________ Were you formed for the purpose of investing in the securities being offered? Yes ____ ☐ No ____ If an individual: ☐ Residence Address:___________: ___________________________________________________________________ (Number and Street) City: _________________ State: _____ Zip Code: ________________________________________________________ Telephone Number: _______________________ (City) (State) (Zip Code) Telephone NumberAge: (___) _________________________________________________________________________ Age:­­­­­­­­ ­__________ Citizenship: ____________ Where registered to vote: _______________ If an individual, set Set forth in the space provided below the state state(s), if any, in the United States in which you maintain maintained your residence: If an entity, set forth in residence during the space provided below past two years and the state in the United States in dates during which you made your investment decisionresided in each state: Are you a director or executive officer of the Company? Yes ____ ☐ No ____ ☐ Social Security or Taxpayer Identification No.: _________________________________________________________

Background Information. Name of Beneficial Owner of the Shares:____________________________________________________________ Securities: Business Address:_______________________________________________________________________________ (Number and Street) City: _________________ State: _____ Zip Code: ___________ Telephone Number: ______________________________________________________________________ If a corporation, partnership, limited liability company, trust or other entity: Type of entity: _________________________ (City) (State) (Zip Code) Telephone NumberState of formation: (___) _________________________________________________________________________ Type Approximate Date of entity:________________________________________________________________formation: __________________ Were you formed for the purpose of investing in the securities being offered? Yes ____ o No ____ If an individual: o Residence Address:___________: ___________________________________________________________________ (Number and Street) City: _________________ State: _____ Zip Code: ________________________________________________________ Telephone Number: _______________________ (City) (State) (Zip Code) Telephone NumberAge: (___) _________________________________________________________________________ Age:­­­­­­­­ ­__________ Citizenship: ____________ Where registered to vote: _______________ If an individual, set Set forth in the space provided below the state state(s), if any, in the United States in which you maintain maintained your residence: If an entity, set forth in residence during the space provided below past two years and the state in the United States in dates during which you made your investment decisionresided in each state: Are you a director or executive officer of the CompanyCorporation? Yes ____ o No ____ o Social Security or Taxpayer Identification No.: _________________________________________________________