INVESTOR REGISTRATION

Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Office of Foreign Assets Control Certification *

I certify that I am not, and have never been, listed on or investigated by the Office of Foreign Assets Control (OFAC) Sanctions List. I certify that I do not have any personal, professional, or financial affiliation with any persons, groups, or entities who are or have previously been listed on or investigated by the OFAC Sanctions List.

I agree to the Office of Foreign Assets Control certification.