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Octagon Investment Partners IX, Ltd. JPMorgan - Irish Stock Exchange

Octagon Investment Partners IX, Ltd. JPMorgan - Irish Stock Exchange

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Dated:<br />

[Insert Name of Purchaser Above]<br />

By:<br />

Name:<br />

Title:<br />

__________________________<br />

Aggregate original issue price of Preferred Shares: U.S.$<br />

Taxpayer identification number:<br />

Address for notices:<br />

Wire transfer information for payments:<br />

Bank:<br />

Address:<br />

Bank ABA#:<br />

Account #:<br />

Telephone:<br />

Facsimile:<br />

Attention:<br />

FAO:<br />

Attention:<br />

Denominations of certificates (if more than one):<br />

Registered name:<br />

cc:<br />

<strong>Octagon</strong> <strong>Investment</strong> <strong>Partners</strong> <strong>IX</strong>, <strong>Ltd</strong>.<br />

c/o Maples Finance Limited<br />

P.O. Box 1093GT<br />

Queensgate House<br />

South Church Street, George Town<br />

Grand Cayman, Cayman Islands<br />

A-5

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