Please complete this form, which requests the information necessary to draft and send you an engagement letter. Please let me know if you have any trouble completing or returning the form.

I. CONTACT INFORMATION

Contact information: Please fill in all known information

Prefix

First name *

Middle name

Last name *

Company

Emails

Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

PrimaryDefault email false

Add email

Addresses

Street address

Country

City

State/Region

Province/Region

Zip/Postal code

Address type

PrimaryDefault address false

Add address

Phone numbers

Phone number

Type

Primary

Add phone number

Title of Principle Contact

II. COMPANY INFORMATION - if already formed

Enter full legal name

if formed or expected to be formed

Type or Purpose of Business:

Jurisdiction of Formation:

Date of Incorporation:

Type of Company:

Limited Liability Company (LLC)

Limited Partnership

Corporation (c-corp for tax purposes)

Corporation (s-corp for tax purposes)

Benefit Corporation (or Public Benefit Corporation)

Sole Proprietorship

Non-profit corporation

Other

Please specify.

Company's Primary Office Address:

Is this person an authorized signatory for the Company?

Yes

Pease provide the name and title of authorized signatory for engagement letter: Name: Title:

III. POTENTIAL CONFLICT INFORMATION

Description of matter for engagement:

Does the matter for which you expect to engage our office involve any parties who may have interests adverse to you or your Company?

Yes

If yes, please provide name of the party for conflict check process. For example, list name of company or fund receiving investment from you or name of investor providing investment to you.

THANK YOU

When you are finished, please click the "Submit" button.