EFTA01390252.pdf

GLDUS138 Ian Slome Eachprospective Investor is required to complete either the column titled "ForIndividuals" or the column titled "For Entities -. as applicable. I am investing as an: ❑ Individual ❑ Entity I am an Ind al m Entity that is a U.S. Person': ❑ Yes ❑ 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 Tax Identification No.: 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-0094695 CONFIDENTIAL SDNY_GM_00240879 EFTA01390252