Form Loe - Notice Of Limited Offering Exemption - Delaware Department Of Justice Page 4

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6. Investor(s) Information
(Enter contact information for each person residing in Delaware who has purchased the security
that is being offered.)
Name:
Address:
Telephone Number:
E-Mail Address:
Amount Invested:
Name:
Address:
Telephone Number:
E-Mail Address:
Amount Invested:
Name:
Address:
Telephone Number:
E-Mail Address:
Amount Invested:
Name:
Address:
Telephone Number:
E-Mail Address:
Amount Invested:
(continue on a separate sheet if necessary)

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