QUALIFICATION QUESTIONNAIRE AND AGREEMENT

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The information contained in this Investor Qualification Questionnaire and Agreement is being provided to you in connection with determining whether you are qualified to make an investment in a Sciens Capital Management investment vehicle. All information furnished in completing this questionnaire will be kept confidential.
If the answer to any question is “none” or “not applicable,” please indicate so.

I. GENERAL INFORMATION

Name: *

Marital Status:

Name of Spouse:

Date of Birth:

Residence Address: *

include street, city, state, country and zip code

Residence Telephone Number: *

Facsimile Number: *

E-Mail Address: *

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