Use this template to prepare a Private Placement Questionnaire and Undertaking, to be completed by each person who purchases securities as part of the private placement.

The purchaser must complete the form by answering questions about the transaction, the nature of the relationship between the purchaser and the issuer, which exemption(s) the purchaser is relying upon, any applicable hold periods, and other pertinent information.

This is a generic document in MS Word format, and is not specific to any country or region.