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Subscribers who qualify as Non-Professionals should sign below and return this Self-Certification form to Distributor. Please note that this form may be subject to Distributor s review and approval. Subscriber must notify Distributor as soon as is reasonably practicable in the event that Subscriber no longer qualifies as a NonProfessional. I hereby certify that I qualify as a Non-Professional pursuant to the definition described herein SUBSCRIBER Signature Date Account No. Account Name Ver....

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Based on form subscriber is a document that contains information provided by an individual or entity who has subscribed to a particular form or service.

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