Vascular BioSciences Foreign Investor

For Foreign Investors

Vascular BioSciences respects the privacy of prospective investors. Information will be held in the strictest confidence, and will not be sold, transferred or distributed.

Information regarding private placements available from Vascular BioSciences shall be forwarded to qualified investors only by e-mail unless another means of written verification is requested and agreed to between Vascular BioSciences and the respective qualified investor.

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Personal Information:

* Last Name:
Middle Initial:
* First Name:

Age:
* Date of Birth:

Company
Position / Title:
* Your E-mail Address:

* Residential Address:

* City:
Province or Region:
* Postal Code:

* Country:

* Business Address:

* City:
Province or Region:
* Postal Code:

* Country:

To participate as an investor qualified as an "Foreign Investor" under the United States securities laws and to be able to participate in private placements available from Vascular BioSciences, you must establish your status as an foreign investor by answering the following questions that apply to your description.

1. Do you reside in the United States?
No
Yes

2. If a corporation or trust, are you organized or incorporated under the laws of the United States?
No
Yes

3. Are you an agency or branch of a foreign entity located in the United States?
No
Yes

4. If an employee benefit plan, are you administrated and established outside the United States?
No
Yes

Sign this Questionnaire
To return this Questionnaire through the Vascular BioSciences link,
please enter your full name on the signature line.

The foregoing statements are true and accurate to the best of my information and belief and I will promptly notify Vascular BioSciences of any changes in the foregoing answers.

* Full Name:
* Daytime Phone Number:

* Date:
Fax Number:

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