Important Notice
By completing this form, on your own behalf or in the capacity as a duly authorized representative of an entity (in either capacity, as applicable, “you”) hereby represent, warrant and covenant, in each case, as applicable, to, and for the benefit of, HDAC Technology AG (the "Company") (each, a “Certification” and, collectively, the “Certifications”) that:

You neither are a citizen, resident nor tax resident of the United States of America (hereinafter referred to as the “U.S.”), otherwise constitute a “U.S. person” (as defined in Rule 902 of Regulation S under the U.S. Securities Act of 1933, as amended (the “U.S. Securities Act”)),and you are not otherwise present or located in the U.S., on and as of the date hereof;

You are currently located in : UNITED STATES

You are a legal resident of the following country :

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