Name of authorized signatory *

Name of company / entity *

Email *

Phone *

I am a "qualified institutional buyer" within the meaning of Rule 144A(a)(1) under the U.S. Securities Act of 1933, ad amended.

I am a: Current Holder Prospective Holder Securities Analyst

Amount

Currency USD CAD

Please check the box below to confirm and agree: * I am not a competitor of Empire Homes or any of its subsidiaries or acting on behalf of such a competitor.

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