Name *

First Name

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Tickets are required for all attendees. *

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2

Investor Accreditation *

I hereby certify that I am familiar with the definition of “accredited investor” as defined in Rule 501 of Regulation D issued pursuant to the Securities Act of 1933, as amended.

Investor Accreditation (part 2) *

I also hereby certify that I meet the criteria to qualify as an accredited investor, which is at least one of the following:

I alone, or in combination with my spouse, have net worth in excess of $1 million excluding primary residence.

I have had individual income in excess of $200,000 (if married, $300,000 with spouse) in each of the two most recent calendar years and I have a reasonable expectation of reaching the same income level in the current year.

I am a corporation, partnership or business trust with total assets in excess of $5 million.