Appendix - Cawmere Consulting - Cayman Islands

Name of Company in connection with which this questionnaire is being completed

Any previous name(s) by which you have been known:

Are you completing this questionnaire as a Director or Shareholder:
YesNo

Private Address

Occupation

Passport Number or other identification document:

Have you at any time been convicted of any offence (except a traffic offence, if any) or been subject to sanctions by a judicial, government, professional or other regulatory body? If so, give full particulars:
YesNo

In carrying out your duties will you be acting on the directions or instructions of any other person? If so, give full particulars of such person and the nature of their involvement:
YesNo

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Signature :