The undersigned is informed of the significance of the foregoing representations and warranties and they are made with the full intention that they will be relied upon by the Company in connection with any potential investment made in connection herewith. IN WITNESS WHEREOF, the undersigned has executed this Investor Questionnaire this ___ day of __________, 201__. (Check one) [ ] Individually Signature of Investor Signature of Co-Investor [ ] Joint tenants with If any rights of survivorship [ ] Tenant in Common Print Name Print Name [ ] In partnership* [ ] As custodian, trustee or agent for Title, if applicable Title, if applicable _______________** [ ] Corporation *** ______________________ Mailing Address Mailing Address * If a partnership, please include a copy of City, State, Zip City, State, Zip partnership agreement and certificate authorizing investment. Social Security Number or Social Security Number or Taxpayer Identification Taxpayer Identification ** If a custodian, trustee Number Number or agent, please include trust, agency or other agreement and certificate authorizing investment. *** If a corporation, please include articles of incorporation; certificate that investment was duly authorized, with corporate resolution or other document authorizing investment attached; and certificate of incumbency of officers.
The undersigned is informed of the significance of the foregoing representations and warranties and they are made with the full intention that they will be relied upon by the Company in connection with any potential investment made in connection herewith. IN WITNESS WHEREOF, the undersigned has executed this Investor Questionnaire this ___ day of __________, 201__. (Check one) [ ] Individually [ ] Joint tenants with rights of survivorship [ ] Tenant in Common [ ] In partnership* [ ] As custodian, trustee or agent for _______________** [ ] Corporation *** ______________________ * If a partnership, please include a copy of partnership agreement and certificate authorizing investment. ** If a custodian, trustee or agent, please include trust, agency or other agreement and certificate authorizing investment. *** If a corporation, please include articles of incorporation; certificate that investment was duly authorized, with corporate resolution or other document authorizing investment attached; and certificate of incumbency of officers. Signature of Investor Print Name Title, if applicable Mailing Address City, State, Zip Social Security Number or Taxpayer Identification Number Signature of Co-Investor If any Print Name Title, if applicable Mailing Address City, State, Zip Social Security Number or Taxpayer Identification Number
Thrive-Form-Investor-Questionnaire-Private-Offering.docx