EFTA Document EFTA01394317

GLDUS129 OF Enterpnses Each prospective Investor is required to complete either the column titled "For Individuals" or the column titled "For Entities-. as applicable. I ant investing as an: K Individual K Entity I am an Intik m Entity that is a U.S. Person': K Yes K No FOR INDIVIDUALS: FOR ENTITIES: Type of Individual: Type of Entity: State/Province and Country of Residence of Jurisdiction of Organization: Investor for Tax Purposes: Domicile: Social Security No. or Tax Identification No: Tax Identification No.: Permanent Address: Permanent Address: Mailing Address (if different from above): Mailing Address (if different from above): Date of Birth: Date of Formation: Telephone No: Telephone No: Email Address: Email Address: 6 For definition of "U.S. Person'. please see Rule 902(k) of Regulation S under the Securities Act PROPRIETARY AND CONF7DEN77AL 25 CONFIDENTIAL - PURSUANT TO FED. R. CRIM. P. 6(e) DB-SDNY-0100317 CONFIDENTIAL SDNY GM_00246501 EFTA01394317