GRT Capital Partners

The Consultant or Investment Adviser is an investment professional or
company that is obtaining information for a User that is a: *

Family Office: The User will be investing under the auspices of a Family Office.

Benefit Plan (pension plan, IRA, self-employed plan, state plan)

Investment Entity (corporation, partnership, limited liability company, business trust, tax exempt organization)

Fund of Funds

Trust (non-business)

Natural Person

Other

The Broker is a registered broker that is seeking information for a User that is: *

Family Office

Benefit Plan (pension plan, IRA, self-employed plan, state plan)

Investment Entity (corporation, partnership, limited liability company, business trust, tax exempt organization)

Fund of Funds

Trust (non-business)

Natural Person

If the Broker is seeking information for its own proprietary accounts, it must be "accredited investor" as defined below. Please indicate which of the following apply:

The User is registered with the United States Securities and Exchange Commission as a broker or dealer or an investment company; or

The User has elected to be treated or qualifies as a "business development company" (within the meaning of Section 2(a) (4.8) of the Investment Company Act of 1940 or Section 202(0) (22) of the Investment Advisers Act of 1940).

Other

Family Office

The amount of investments under the auspices of the Family Office is: *
$

The Users under the purview of the Family Office have invested in:

long-short pooled investment vehicles
long only pooled investment vehicles
foreign securities
high risk investments

The Family Office is seeking information for a User that is a: *

Benefit Plan (pension plan, IRA, self-employed plan, state plan)

Investment Entity (corporation, partnership, limited liability company, business trust, tax exempt organization)

Trust (non-business)

Natural Person

Other

Benefit Plan

The User has gross investment assets of: *
$ 1 � 5 million
$ 5 � 20 million
over $ 20 million

Under SEC Regulations, the User must be an "accredited investor" as defined below. Please indicate which of the following apply *:
The User is an employee benefit plan (within the meaning of the Employee Retirement Income Security Act) and if the investment decision for the employee benefit plan is made by a plan fiduciary which is a bank, insurance company, or registered investment adviser, or if the employee benefit plan has total assets in excess of $5 million, or if the employee benefit plan is a self-directed plan, with investment decisions made solely by persons that are accredited investors.

The User is an employee benefit plan established and maintained by a state, its political subdivisions or any agency or instrumentality of a state or its political subdivisions, which has total assets in excess of $5,000,000.

Other

Fund of Funds

The name of the Fund of Funds is: *

The User has gross investment assets of: *
$ 1 � 5 million
$ 5 � 20 million
over $20 million

The Fund of Funds is seeking to invest in a pooled investment vehicle that follows an investment strategy which is (please describe):

Under SEC Regulations, the User must be an "accredited investor" as defined below. Please indicate which of the following apply: *

The User is an entity with total assets in excess of $5,000,000 (which was not formed for the purpose of investing in any GRT Capital Partners products and) which is one of the following:

corporation;
partnership;
limited liability company; or
business trust;

Other

Trust

The User has gross investment assets of: *

$ 1 � 5 million
$ 5 � 20 million
over $20 million

Has the Trust invested in alternative investments such as pooled investment vehicles? *

Yes
No

Under SEC Regulations, the User must be an "accredited investor" as defined below. Please indicate which of the following apply: *

The User is a personal (non-business) trust with total assets in excess of $5,000,000 (which was not formed for the purpose of investing in any GRT products and) whose decisions to invest in any GRT product will be directed by a person who has such knowledge and experience in financial and business matters that he is capable of evaluating the merits and risks of an investment in the GRT products.

Other

The Family Office is seeking information for a User that is a: *

Benefit Plan (pension plan, IRA, self-employed plan, state plan)

Investment Entity (corporation, partnership, limited liability company, business trust, tax exempt organization)

Trust (non-business)

Natural Person

Other

Under SEC Regulations, the User must be an "accredited investor" as defined below. Please indicate which of the following apply *:
The User is an employee benefit plan (within the meaning of the Employee Retirement Income Security Act) and: -- the investment decision for the employee benefit plan is made by a plan fiduciary which is a bank, insurance company, or registered investment adviser, -- the employee benefit plan has total assets in excess of $5 million, or -- the employee benefit plan is a self-directed plan, with investment decisions made solely by persons that are accredited investors.

The User is an employee benefit plan established and maintained by a state, its political subdivisions or any agency or instrumentality of a state or its political subdivisions, which has total assets in excess of $5,000,000.

Other

Under SEC Regulations, the User must be an "accredited investor" as defined below. Please indicate which of the following apply * The User is:

A bank as defined in section 3(a)(2) of the Securities Act of 1933,
A savings and loan association or other institution as defined in section 3(a)(5)(A) of the Securities Act of 1933,
An insurance company as defined in section 2(a)(13) of the Securities Act of 1933,
An investment company registered under the Investment Company Act of 1940,
A business development company as defined in section 2(a)(48) of the Securities Act of 1933, or
A Small Business Investment Company licensed by the U.S. Small Business Administration under section 301(c) or (d) of the Small Business Investment Act of 1958.

Under SEC Regulations, the User must be an "accredited investor" as defined below. Please indicate which of the following apply: *

The User is an entity with total assets in excess of $5,000,000 (which was not formed for the purpose of investing in any GRT products and) which is one of the following:

corporation;
partnership;
limited liability company; or
business trust;

Other

Under SEC Regulations, the User must be an "accredited investor" as defined below. Please indicate which of the following apply: *

The User is a natural person whose individual net worth, or joint net worth with that person's spouse, at the time of purchase exceeds $1,000,000.

The User is a natural person who had an individual income in excess of $200,000 in each of the last two calendar years, or joint income with that person's spouse, in excess of $300,000 in each of those years, and has a reasonable expectation of reaching the same income level in this calendar year.

Other

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