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First Name:
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Last Name:
Company Name:
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Street Address:
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City:
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State/Provice:
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Zip/Postal Code:
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Country:
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Work Phone:
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Home Phone:
Fax:
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E-Mail Address:
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Do you
believe that you have sufficent knowledge and experience in financial
and business matters to evaluate the merits and risks of hedge funds
and managed accounts?
Yes
No
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Choose one of the following
that best describes you?
Individual
I am an employee representative of
a Qualified Institution
Pension Plan
Family Office
Endowment / Foundation
Bank / Insurance Company
Consultant
Financial Intermediary
Other:
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U.S. PERSONS:
Are you or are you acting for a U.S. Person?
(A US person is defined as an individual who is a national or permanent
resident alien of the US and any corporation, business association,
partnership, trust, or other judicial entity incorporated or permanently
residing in the U.S.)
Yes
No
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I. Accredited Investors
(Choose A or B) A. Individual Investors:
Are you, in your capacity as an individual, rather than as an agent
of a legal entity, an accredited investor?
Yes
No
Click
here for definition of an "Accredited Investor".
B. Entities:
Are you an agent of a legal entity that is an accredited investor?
Yes
No
Click
here for definition of an "Entity" which is an "Accredited
Investor".
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II. Qualified Purchaser
Are you or are you acting for a "qualified purchaser"?
Yes
No
Click
here for definition of a "Qualified Purchaser".
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HEDGE
FUNDS AND MANAGED ACCOUNT INVESTMENTS INVOLVE A DEGREE OF RISK AND
ARE SUITABLE ONLY FOR PERSONS OF SUBSTANTIAL FINANCIAL MEANS WHO
HAVE NO NEED FOR LIQUIDITY OF THEIR INVESTMENTS AND WHO COULD BEAR
THE ENTIRE LOSS OF THEIR INVESTMENT.
The current value of
my liquid assets (cash, freely marketable securities, cash surrender
value of life insurance, etc.) is sufficient to provide for my current
and anticipated needs and possible contingencies, so that I am capable
of bearing the economic risk of hedge fund and managed account investments.
I hereby acknowledge
that the information I will be able to access on Rothschild Solomon's
website is not an Offer, but is for information purposes only. I
will not share my password. Any further formal relationship with
Rothschild Solomon may require additional steps to insure adherence
to local rules and regulations
I hereby represent,
warrant and covenant that: (i) I am not, nor is any person or entity
controlling, controlled by or under common control with me, a person
or entity that acts, directly or indirectly, (a) in contravention
of any U.S. or international laws and regulations, including anti-money
laundering regulations or conventions, (b) on behalf of terrorists
or terrorist organizations, including those persons or entities
that are included on the List of Specially Designated Nationals
and Blocked Persons maintained by the U.S. Treasury Department's
Office of Foreign Assets Control (the list may be accessed on the
web at www.treas.gov/ofac ),
as such list may be amended from time to time, (c) for a senior
foreign political figure, any member of a senior foreign political
figure's immediate family or any close associate of a senior foreign
political figure, unless Rothschild Solomon, after being specifically
notified by you that you are such a person, determines that access
shall be permitted, or (d) for a foreign shell bank, and (ii) to
the extent that I have any beneficial owners, (a) I have carried
out thorough due diligence to establish the identities of such beneficial
owners, and (b) based on such due diligence, I reasonably believe
that no such beneficial owners are persons described in (i) above.
What is
your individual or joint annual income?
(May be combined with your spouse)
Below $200,000 USD
$200,000 - 300,000
$300,000 - $400,000
$500,000 - $1 Million
$1 Million +
Other:
What is
your individual or joint total net worth? (May
be combined with your spouse)
Less than $1 Million
$1 Million - $2 Million
$2 Million - $4 Million
$4 Million - $5 Million
$5 Million - $10 Million
Other:
Annual
Earnings:
2000:
2001:
2002:
Preferred
size of investment:
Minimum $:
Maximum $:
Portfolio
Analysis:
Hedge Fund
Stocks
Bonds
Mutual Funds
IRA / Keogh
Cash / CD's
Bank Savings
Real Estate
Insurance
Gold / SIlver
Commodities
Other
If Financial Intermediary,
which of the following are you?
Independent Registered
Investment Advisor
Associated with Broker
Dealer
Firm Name:
How many
years experience investing in hedge funds do you or your clients
have?
None
1-5 years
6+ years
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By electronically
signing below, I am affirming that all the information contained
herein is true and correct to the best of my knowledge and belief.
Signature:
(please type your name):
If responses are received
during business hours, a response should take no longer than 2 to
4 Hours. All information is stictly confidential.