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