Certification Form

CERTIFICATION FORM

Please complete all fields before submitting this form. State is not required for international requests.

By submitting this Certification Form, the person identified below (the “Market Participant”) hereby represents and warrants to A360 Media, LLC (the “Company”) as follows:

First Name

Last Name

Company

Street Address

City

Country

Phone Number

Email Address

*Market Participant Details

It is the beneficial owner, or is acting on behalf of a beneficial owner, of debt securities or other indebtedness of the Company

It is a prospective beneficial owner, or is acting on behalf of a prospective beneficial owner, of debt securities or other indebtedness of the Company

It is a bona fide securities analyst who regularly covers or intends to cover the Company and/or debt securities or other indebtedness of the Company

It is a bona fide market maker who regularly makes or intends to make a market in debt securities or other indebtedness of the Company

Certification Form

CERTIFICATION FORM

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