Please choose one of the following:

I am not a United State citizen;

I am not a United States resident (meaning I spend less then 180 days in the United State each year and do not hold a "Green Card" or other form of immigrant visas);

I am not otherwise a U.S. Person as that term is defined previously; or

I am not physically present in the United State at this time.

First Name *:

Last Name *:

Company:

Address 1:

Address 2:

City:

State or Province:

Zip / Postal Code:

Country *:

Phone Number *:

E-mail *:

Please describe your investment experience (e.g. amount invested, length of time invested, etc.):

I certify that the above representations are true and accurate.

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