Accredited Investors Form (Page 2 of 3) in pdf

Accredited Investors Form Page 2

Accredited Investor Form

Each final printed PPM shall provide as an attachment an Accredited Investors Status

Confirmation Form, which shall include as minimum information the following particulars:

IN WITNESS WHEREOF I/we …………….. confirm that I/we am/are (an) accredited

investor(s) (as defined below), and further confirm that I/we have read and understood the

definition of “accredited investor” as set out below. Furthermore, I/we have read the “risk

factors” section of the Private Placement Memorandum dated _______, and understand the risk

nature of the financial instruments on offer.

An accredited investor is defined as:

Please tick [√] as appropriate

Category

Individuals holding financial assets (either

singly or jointly with their spouse) of US$

1,000,000 or more, excluding that person’s

principal place of residence: or

Companies, partnerships, trusts or other

commercial undertakings, which have financial

assets available for investment of not less than

US$1,000,000; or

Governments, supranational organisations,

central banks or other national monetary

authorities, and state organisations whose main

activity is to invest in financial instruments

(such as state pension funds).

THE PURCHASER HAS EXECUTED THIS AGREEMENT ON: ……/……/2010

A. Subscription and Payment Arrangement:

(i) Number of shares to be purchased @ BD/US$ …. each: ____________________ shares

(Number in words)

(ii) Purchase price to be paid for shares ….

BD/US$ _____________________

(Amount in words)

(iii) Arrangement Fee @ ….. % of (i)

BD/US$ _____________________

(iv) Placement Fee @ ….. % of (i)

BD/US$ _____________________

(v) Total Funds to be Remitted:

BD/US$ _____________________

(Sum of (ii), (iii), (iv))

OFS: Offering of Securities

2012

Appendix 11: Accredited Investor Form: Page 1 of 2

Accredited Investors Form Page 2