CONFIDENTIAL SUBSCRIBER INFORMATION. Name of Subscriber -------------------------------------------------------------------------------------------------------------------------- If Subscriber is an Entity Provide Name Year Formed State of Formation -------------------------------------------------------------------------------------------------------------------------- Street Address City Zip -------------------------------------------------------------------------------------------------------------------------- Subscriber SS# or EIN/TIN Cell Phone Number Work Phone Number Home Phone Number -------------------------------------------------------------------------------------------------------------------------- Subscriber's Age Date of Birth Married (Y/N)/Divorced # of Dependants -------------------------------------------------------------------------------------------------------------------------- Name and Address of Subscriber's Current Employer -------------------------------------------------------------------------------------------------------------------------- Type of Business of Subscriber Position/Title Number of Years -------------------------------------------------------------------------------------------------------------------------- College/Degree Graduate School/Degree Professional Licenses -------------------------------------------------------------------------------------------------------------------------- List Previous Investment Experience Number of Years -------------------------------------------------------------------------------------------------------------------------- List Previous Private Placement Investments Total Invested -------------------------------------------------------------------------------------------------------------------------- List any Securities Currently Owned Total Value -------------------------------------------------------------------------------------------------------------------------- How does Subscriber Know the Company? -------------------------------------------------------------------------------------------------------------------------- Name of Primary Financial Institution Address Phone Number --------------------------------------------------------------------------------- Name in which Subscribed Shares will be Held. (check one below) |_| Individually |_| A married man(woman) as his(her) separate property |_| Community property |_| JTWROS |_| Tenants in common |_| Other (Describe): ____________________________________...
CONFIDENTIAL SUBSCRIBER INFORMATION. The limited information obtained by Participating Entity and its Third-Party Enrollers from Participating Entity’s employees and made available by PEBA Insurance Benefits to Participating Entity and its Third- Party Enrollers from EBS. This information is limited to information already obtained by Participating Entity from its employees; and is limited to the employee’s name, address, Social Security Number, date of birth, salary, marital status, beneficiary information and status of enrollment on the state insurance program and excludes medical information and claim history of health information.
CONFIDENTIAL SUBSCRIBER INFORMATION. Name of Subscriber If Subscriber is an Entity Provide Name Year Formed State of Formation Street Address City Zip Subscriber SS# or EIN/TIN Cell Phone Number Work Phone Number Home Phone Number Subscriber’s Age Date of Birth Married (Y/N)/Divorced # of Dependants Name and Address of Subscriber’s Current Employer Type of Business of Subscriber Position/Title Number of Years College/Degree Graduate School/Degree Professional Licenses List Previous Investment Experience Number of Years List Previous Private Placement Investments Total Invested List any Securities Currently Owned Total Value How does Subscriber Know the Company? Name of Primary Financial Institution Address Phone Number Name in which Subscribed Units will be Held. (check one below) q Individually q A married man(woman) as his(her) separate property q Community property q JTWROS q Tenants in common q Other (Describe): ____________________________________ Aggregate Number of Subscribed Units Amount Invested ($) Subscriber’s Signature Date
