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* Company Name:
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Title:
You are completing this information on behalf of:
Yourself
Your Organization
Both
Are you an accredited investor in accordance with Rule 501(a) of Regulation D of the Securities Act of 1933?
Yes
No
If yes, please select a category that most accurately describes your specific situation
Individual - I am a natural person whose individual investments, or joint investments with my spouse, as of the date hereof exceeds $1,000,000 excluding the individual's primary residence.
Individual - I am a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with my spouse in excess of $300,000 in each of those years and I have a reasonable expectation of reaching the same income level in the current year.
Entity Not Formed For The Specific Purpose Of Acquiring The Security Offered - I am an organization described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended, a corporation, a similar business trust, or partnership, not formed for the specific purpose of acquiring any specific security, with total assets in excess of $5,000,000.
Regulated Entity - I am (i) a U.S. bank or any banking institution organized under the laws of any state, territory or the District of Columbia, the business of which is substantially confined to banking and is supervised by the State or Territorial banking commission or similar official agency, (ii) a U.S. savings and loan association or other similar institution, whether acting in its individual or fiduciary capacity; (iii) a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934; (iv) a U.S. insurance company; or (v) an investment company registered under the Investment Company Act of 1940.
Business Development Company - I am a “business development company” as defined in the Investment Company Act of 1940.
Private Business Development Company - I am a “private business development company” as defined in the Investment Advisers Act of 1940.
Small Business Investment Company - I am a “small business investment company” licensed by the U.S. Small Business Administration under Section 301(c) or 501(c)(3) of the Small Business Investment Act of 1958.
Employee Benefit Plan - I am an “employee benefit plan” within the meaning of Title I of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”), and either (i) the investment decision to invest is made by a plan fiduciary, as defined in ERISA, which is either a bank, savings and loan association, insurance company, or registered investment adviser; or (ii) the employee benefit plan has total assets in excess of $5,000,000; or (iii) if a self-directed plan, the investment decisions are made solely by persons that are “accredited investors”.
State Plan - I am a plan established and maintained by a State, its political subdivisions, or any agency or instrumentality of a State or its political subdivisions, for the benefit of its employees, if such plan has total assets in excess of $5,000,000.
Trust - I am a trust with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring any specific security, whose purchase is directed by a sophisticated person as described in Regulation D.
Recovable Trust - I am a “recovable trust” that may be amended or revoked at any time by the grantors thereof, an all of the grantors are “accredited investors”.
Are you an accredited investor within the meaning of National Instrument 45-106 Prospectus and Registration Exemptions of the Canadian Securities Administrators?
Yes
No
If yes, select the applicable option below:
A person or company registered under the securities legislation of a jurisdiction of Canada, as an adviser or dealer, other than a person registered solely as a limited market dealer under one or both of the Securities Act (Ontario) or the Securities Act (Newfoundland and Labrador),
An individual registered or formerly registered under the securities legislation of a jurisdiction of Canada, as a representative of a person or company referred to in paragraph (i)
A pension fund that is regulated by either the Office of the Superintendent of Financial Institutions (Canada) or a pension commission or similar regulatory authority of a jurisdiction of Canada,
An individual who, either alone or jointly with a spouse, beneficially owns, directly or indirectly, financial assets having an aggregate realizable value that before taxes, but net of any related liabilities, exceeds $1,000,000,
An individual whose net income before taxes exceeded $200,000 in each of the 2 most recent calendar years or whose net income before taxes combined with that of a spouse exceeded $300,000 in each of the 2 most recent calendar years and who, in either case, reasonably expects to exceed that net income level in the current calendar year,
An individual who, either alone or with a spouse, has net assets of at least $5,000,000,
A person, other than an individual or investment fund, that has net assets of at least $5,000,000 as shown on its most recently prepared financial statements (other than a person created or used solely to purchase or hold securities as an accredited investor),
An investment fund that distributes or has distributed its securities only to:
1. A person that is or was an accredited investor at the time of the distribution,
2. A person that acquires or acquired securities in the circumstances referred to in sections 2.10 “Minimum amount investment” and 2.19 “Additional investment in investment funds”, or
3. A person described in paragraph (i) or (ii) that acquires or acquired securities under section 2.18 “Investment fund reinvestment”,
An investment fund that distributes or has distributed securities under a prospectus in a jurisdiction of Canada for which the regulator or, in Québec, the securities regulatory authority, has issued a receipt,
A person or company in respect of which all of the owners of interests, direct, indirect or beneficial, except the voting securities required by law to be owned by directors, are persons that are accredited investors,
An investment fund that is advised by a person registered as an adviser or a person that is exempt from registration as an adviser, or
A person that is recognized or designated by the securities regulatory authority or, except in Ontario and Québec, the regulator as an accredited investor.
Are you an employee, executive officer, director or consultant of the Fund or of a related entity of the Fund, or a permitted assign of any such person, if participation in the trade is voluntary (for the purpose of this provision, a person includes a trustee, custodian or administrator acting as agent for that person for the purpose of facilitating a trade)?
Yes
No
Are you an Ontario resident and a founder of the fund; an affiliate of a founder of the Fund; a spouse, parent, brother, sister, grandparent, grandchild, or child of an executive officer, director or founder of the Fund, or a person that is a control person of the Fund?
Yes
No
What is your investment knowledge?
Sophisticated
Average
Limited
None
What is your investment horizon?
1-3 years
4-5 years
6-9 years
> 10 years
What is your annual income?
Under $200,000
$200,000-$500,000
$500,000-$1,000,000
Over $1,000,000
What is your Net Financial Assets (excluding real estate)?
Under $200,000
$200,000-$500,000
$500,000-$1,000,000
Over $1,000,000
What is your spouse’s annual income
Under $200,000
$200,000 - $500,000
$500,000 - $1,000,000
Over $1,000,000
Please choose the category that best describes you:
Fund-of-Funds
Bank
Individual
Fund Manager
Pension Fund
Broker-Dealer
Endowment
Insurance Co.
Family office
Consultant
Foundation
Registered Investment Adviser
Third-Party Marketer
What is your risk tolerance?
High
Medium
Low
None
Comments:
You heard about FrontFour through:
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Conference
Database/Index
Current Investor
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Referral

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