Shareholder Transaction Form

"*" indicates required fields

First Name (Legal)*

Last Name (Legal)*

Email*

Phone Number*

Company*

Entity Name (If selling from legal entity, Trust, or LLC)

Street Address (of entity if selling from entity)*

City (of entity if selling from entity)*

State (of entity if selling from entity)*

Zip/Postal Code (of entity if selling from entity)*

Country (of entity if selling from entity)*

Spouse's Name (write none if not married)*

Spouse's Email (write N/A if not married)*

Name of Company Shares Selling*

Number of Shares Selling*

Share Class

Stock Certificate Number (write not exercised if you have not yet exercised options)*

Stock certificate issue date

Upload screenshot or copy stock certificates - if shares are not yet exercised, upload screenshot of proof of options (found in Carta, Share Works, etc)

Max. file size: 50 MB.

Copy of Passport / Drivers License for Compliance Purposes

Max. file size: 50 MB.

Bank Name

Bank Address

Routing Number / IBAN

Account Number