Registration Form

If you are an investor who invested funds with any of the Corporate or Relief Defendants, or are owed money for services performed on behalf of any of the Corporate or Relief Defendants prior to the commencement of the Receiver’s appointment on April 13, 2016, it is imperative that you provide us with your contact information below. Please note that this registration form is not a claim form.  It simply provides your contact information to the Receiver.

 

Title *

First Name *

Middle Initial

Last Name *

Business Name

Address 1 *

Address 2

Address 3

City *

State/Province *

Country *

Zip Code *

Phone *

(Including Country Code and Area Code As applicable)

Alternate Phone

(Including Country Code and Area Code As applicable)

Email *

Account Name

(e.g. John Doe, IRA)

Comments

Are you represented by an attorney?

YesNo
Please provide your attorney's contact information below

Attorney First Name

Attorney Last Name

Firm Name

Street Address

(Include Suite #)

City

State/Province

Country

Zip/Postal Code

Phone

(Including Country Code and Area Code)

Fax

(Including Country Code and Area Code)

Email