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DocuSign Envelope ID: 69E4955D-23F3-4407-84A7-E75FDC837DB9 <br />SIGNATURE: x <br />Equity Owned: % <br />Title: <br />Date: <br />Owner/Officer Name: <br />Citizenship: <br />❑ U.S. ❑ Non-U.S <br />Date of Birth (mm/dd/yyyy): <br />Social Security Number: <br />Home Phone Number: <br />Home Address: <br />City: <br />State: <br />Zip: <br />Years There: <br />❑ Rent El Own <br />Former Address (If less than 1 year at current address): <br />City: <br />State: <br />Zip: <br />Years There: <br />❑ Rent ❑ Own <br />SIGNATURE: x <br />Equity Owned: % <br />Title: <br />Date: <br />Owner/Officer Name: <br />Citizenship: <br />❑ U.S. ❑ Non-U.S <br />Date of Birth (mm/dd/yyyy): <br />Social Security Number: <br />Home Phone Number: <br />Home Address: <br />City: <br />State: <br />Zip: <br />Years There: <br />❑ Rent ❑ Own <br />Former Address (If less than 1 year at current address): <br />City: <br />State: <br />Zip: <br />Years There: <br />❑ Rent ❑ Own <br />SIGNATURE: x <br />Equity Owned: % <br />Title: <br />Date: <br />