Access to empiricalcapital.com is restricted. In order to obtain access, please complete and submit this form. You will be contacted by a member of our Investor Relations team to verify the information you submit, and your user ID and password will be activated. The investment fund described in this website has not been registered under the federal securities laws of the United States, the securities laws of any state, or the laws of any other jurisdiction. This website shall not constitute an offer to sell or the solicitation of an offer to purchase shares of the fund in any jurisdiction. Such an offer may only be made by the private placement memorandum for the fund, and only to investors who meet certain eligibility requirements. This registration form is not an application form to subscribe for interests in or shares of the fund.



Personal Information
*First Name:
*Last Name:
*Email / Username:
*Password:
Company Name:
*Address 1:
Address 2:
*City:
*State:
*Zip:
Country:
*Phone:
Cell Phone:
Title:


1. You are completing this information on behalf of:
Yourself
Your Organization
Both
2. Are you an accredited Investor Per Section 501(a) of Regulation D
Yes No
If yes, please select one:
I am an individual who has a net worth, including assets held jointly with my spouse, if appropriate, of not less than $1,000,000.

I had individual income (exclusive of any income attributable to my spouse) of more than $200,000 in each of the past two years, or joint income with my spouse of more than $300,000 in each of those years, and reasonably expect to reach the same income level in the current year.

I represent a bank as defined in Section 3(a)(2) of the Securities Act of 1933.

I represent a savings and loan association as defined in Section 3(a)(5)(A) of the Securities Act of 1933.

I represent an insurance company as defined in Section 2(13) of the Securities Act of 1933.

I represent an investment company registered under the Investment Company Act of 1940.

I represent a business development company as defined in Section 2(a)(48) of the Investment Company Act of 1940.

I represent a Small Business Investment Company licensed by the U.S. Small Business Administration under Section 301(c) or (d) of the Small Business Investment Act of 1958.

I represent (a) a trust with total assets in excess of $5,000,000, and (b) which was not formed for the specific purpose of acquiring a LP Interest, and (c) purchases are directed by a person who has such knowledge and experience in financial and business matters that he is capable of evaluating the merits and risks of investment in the Fund.

I represent a plan established and maintained by a state, its political subdivisions, or any agency or instrumentality of a state or its political subdivisions, for the benefit of its employees, if such plan has total assets in excess of $5,000,000.

I represent a private business development company as defined in Section 202 (a) (22) of the Investment Advisers Act of 1940 or a broker-dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934.



I represent an employee benefit plan within the meaning of Title I of the Employee Retirement Income Security Act of 1974, and one of the following applies
     the investment decision is being made by a plan fiduciary, as defined in Section 3(21) of such Act, which is either a bank, insurance company or registered investment advisor
     the plan has total assets in excess of $5,000,000
     if a self-directed plan, investment decisions are made solely by accredited investors


I represent an entity that (a) has total assets in excess of $5,000,000, and (b) was not formed for the specific purpose of acquiring a LP Interest, and (c) is one of:
     an organization (tax exempt organization) described in Section 501(c)(3) of the Internal Revenue Code of 1986, as amended (the "Internal Revenue Code"), or
     a corporation, or
     a Massachusetts or similar business trust, or
     a partnership or limited liability company
3. Are you a qualified Clients Per Rule 205-3 Under the Investment Advisers Act of 1940
Yes No
If yes, please select one:
I am a natural person or company who has at least $750,000 under management with the General Partner and Investment Manager, including any LP Interest being subscribed for or currently held;

I am a natural person or a company who as of the date hereof has a net worth (in the case of a natural person, together with assets held jointly with a spouse) of more than $1,500,000;

I am a natural person or a company who as of the date hereof is a "qualified purchaser" as defined under Section 2(a) (51) (A) of the 1940 Act;

I represent a private investment entity that is excepted from the definition of investment company under Section 3(c)(1) or 3(c)(7) of the 1940 Act, all of the beneficial owners of which meet one of the three (3) tests enumerated immediately above;

I am a natural person who as of the date hereof is an executive officer, director, trustee, general partner, or person serving in a similar capacity, of the General Partner or Investment Manager; or

I am a natural person who as of the date hereof is an employee of the General Partner or Investment Manager (other than an employee performing solely clerical, secretarial or administrative functions) who, in connection with his or her regular functions or duties, participates in the investment activities of the General Partner or Investment Manager, provided that such employee has been performing such functions and duties for or on behalf of the General Partner or Investment Manager or substantially similar functions or duties for or on behalf of another company for at least 12 months.
4. What investment styles suit your particular interest in hedge funds?
5. What are your return objectives?
6. What is your investment time horizon?
Long Term (>5 years)
Med Term (2-5 years)
Short Term (<2 years)
7. What is your risk tolerance?
High (Agressive)
Moderate
Low (Conservative)
8. Do you invest in hedge funds?
Yes No
If yes,
How many years have you been investing in hedge funds?
Approximately how many hedge funds are you invested in?
What percentage do hedge funds comprise of your portfolio?
Do you leverage your investments in hedge funds? Yes No
How much leverage do you utilize?
Who is your leverage provider?
What are the terms of your leverage with that provider?
What is the approximate total value (in US$) of your hedge fund portfolio?
What is the approximate total value (in US$) of your current credit exposure?
What is your average investment size?
Once you invest, how long does it take to get to your average investment size?
What is your turnover in hedge fund investments?
9. Please choose the category that best describes you:
Fund-of-Funds
Bank
Individual
Fund Manager
Pension Fund
Broker-Dealer
Endowment
Insurance Co.
Family office
Consultant
Foundation
Registered Investment Adviser
Third-Party Marketer
10. If you selected Funds-of-Funds:
What percentage of your assets are institutional investors versus high-net worth?
Do you have lock-up money?
What is your average investment size?
Once you invest, how long does it take to get to your average investment size?
How soon can a manager come visit us?
11. You heard about Empirical Capital through (please describe in detail):
News Article:
Conference:
Database/Index:
Current Investor:
Third Party:
Other (Referral):


Anti-Money Laundering Representations:

  1. I hereby acknowledge that the Fund seeks to comply with all applicable laws and regulations concerning money laundering and related activities. I represents that the amounts I contribute to the Fund are not and will not be directly or indirectly derived from activities that may contravene federal, state or international laws and regulations, including anti-money laundering laws and regulations. Federal regulations and Executive Orders administered by the U.S. Treasury Department's Office of Foreign Assets Control ("OFAC") prohibit, among other things, the engagement in transactions with, and the provision of services to, certain foreign countries, territories, entities and individuals (the lists of OFAC prohibited countries, territories, persons and entities can be found at www.treas.gov/ofac). In addition, the programs administered by OFAC (the "OFAC Programs") prohibit dealing with individuals or entities in certain countries regardless of whether such individuals or entities appear on the OFAC lists.
  2. I hereby represent and warrant that none of (i) my, (ii) any person controlling or controlled by me, (iii) if I am representing a privately held entity (including a corporation, limited liability company, trust or partnership), to the best of my knowledge after conducting due diligence, any person having a beneficial interest in me, or (iv) to the best of my knowledge after conducting due diligence, any person for whom I am acting as agent or nominee in connection with this investment, is (x) a country, territory, individual or entity named on an OFAC list, or is a person or entity prohibited under the OFAC Programs or (y) is a senior foreign political figure, any immediate family member or close associate of a senior foreign political figure.
  3. If I represent a non-U.S. banking institution (a "Foreign Bank") or if I receive deposits from, makes payments on behalf of, or handles other financial transactions related to a Foreign Bank, I represent and warrant to the Fund that (i) the Foreign Bank has a fixed address, other than solely an electronic address, in a country in which the Foreign Bank is authorized to conduct banking activities, (ii) the Foreign Bank employs one or more individuals on a fulltime basis, (iii) the Foreign Bank maintains operating records related to its banking activities, (iv) the Foreign Bank is subject to inspection by the banking authority that licensed the Foreign Bank to conduct banking activities; and (v) the Foreign Bank does not provide banking services to any other Foreign Bank that does not have a physical presence in any country and that is not a regulated affiliate.
  4. I acknowledge that if any of the foregoing representations, warranties or covenants ceases to be true or if the General Partner no longer reasonably believes that it has satisfactory evidence as to their truth, notwithstanding any other agreement to the contrary, the General Partner may be required to freeze my investment in the Fund, either by prohibiting additional investments, declining or suspending any withdrawal requests and/or segregating the assets constituting the investment in accordance with applicable regulations, or my investment may immediately be involuntarily distributed by the Fund. In the event that the Fund is required to take any of the foregoing actions, I understand and agree that I shall have no claim against the Fund, the General Partner, the Investment Manager or any of their respective Affiliates, for any form of damages as a result of any of the aforementioned actions.
  5. I understand and agree that any withdrawal proceeds paid to me will be paid to the same account from which my investment in the Fund was originally remitted, unless the General Partner, in its sole discretion, agrees otherwise.
  6. I understand that the Fund, the General Partner or the Investment Manager may release confidential information about me and, if applicable, any underlying beneficial owners, to proper authorities if required by law or if the General Partner or Investment Manager, in its sole discretion, determines that it is in the best interests of the Fund in light of relevant rules and regulations under the laws set forth above.
  7. If I represent a financial institution (as defined under the Anti-Money Laundering Act), I represent that it has an appropriate anti-money laundering program that complies with all applicable laws, rules and regulations and has obtained appropriate background information regarding all of the officers, managers, directors, trustees and beneficial owners of the institution.


Thank you very much for your time. By pressing the "Submit/I Agree" button below, you agree that you have filled in this questionnaire completely, truthfully and to the best of your ability and that you also have read and agree to the Terms of Use Agreement which you should review carefully.