Extract to table

All information must be typed or printed legibly in ink

All information must correspond exactly to the legal name and organizational details as set forth in the applicant's charter documents or certificate of formation, as applicable

Full Legal Name of Applicant (Issuer): ________________________________________ State or Jurisdiction of Incorporation / Organization: ________________________________________ Principal Office Address: Street Address: ________________ City: ________ State: ___ ZIP Code: ___ Federal Employer Identification Number (EIN): _ – ____ Name and Title of Authorized Signatory: Name: __________________ Title: __________________ Note: The authorized signatory must be a duly authorized officer, general partner, managing member, or other person authorized to bind the applicant

If the applicant is an individual, the individual must sign personally

The Applicant further consents that any such action or proceeding against the Applicant may be commenced in any court of competent jurisdiction and proper venue within such state or jurisdiction by service of process upon said administrator, commissioner, or other designated official, and that such service of process shall have the same force and validity as if served personally upon the Applicant

This Consent to Service of Process shall be irrevocable, shall remain in force so long as any liability exists under the securities laws of such state or jurisdiction, and shall be binding upon the Applicant and its successors and assigns