• Investor Eligibility & Representation Form

INVESTOR ELIGIBILITY & REPRESENTATION FORM

Elysium Management Company
(United States & South Africa)

Effective Date: 27th Feburary 2026

IMPORTANT NOTICE

This Investor Eligibility & Representation Form (“Form”) must be completed and accepted prior to the issuance of any non-voting shares in Elysium Management Company (“Elysium” or the “Company”).

This Form does not replace the Shareholder Agreement.
It supplements the Shareholder Agreement and is legally binding.

By proceeding, you acknowledge that you are making legally enforceable representations to the Company.

SECTION 1 – INVESTOR IDENTIFICATION

The undersigned investor (“Investor”) represents that:

  • Full Legal Name: __________________________

  • Country of Residence: ______________________

  • Nationality: _______________________________

  • Date of Birth: _____________________________

The Investor confirms that all information provided is true, accurate, and complete.

SECTION 2 – AGE & LEGAL CAPACITY

The Investor represents and warrants that:

☐ I am at least 18 years of age.
☐ I have full legal capacity to enter into binding agreements.
☐ I am not acting on behalf of an undisclosed third party.

SECTION 3 – INVESTMENT INTENT

The Investor represents that:

☐ The shares are being acquired for my own account.
☐ I am acquiring the shares for long-term holding purposes.
☐ I understand that the shares are subject to a mandatory 4-year lock-up period.
☐ I do not intend to resell, distribute, or transfer the shares in violation of applicable securities laws.

SECTION 4 – UNDERSTANDING OF RISK

The Investor acknowledges and agrees that:

☐ The shares are non-voting.
☐ The shares are not publicly listed at the time of issuance.
☐ There is no guaranteed secondary market.
☐ A future IPO is not guaranteed.
☐ The value of shares may increase, decrease, or become worthless.
☐ The investment involves substantial risk.
☐ I am capable of bearing the economic risk of this investment.

SECTION 5 – ACCREDITED / SOPHISTICATED INVESTOR STATUS (USA)

(Complete if you are a U.S. person)

The Investor represents that:

☐ I qualify as an “Accredited Investor” under Rule 501 of Regulation D; OR
☐ I am not an Accredited Investor but understand this offering is being made in reliance on an applicable exemption from registration.

The Investor understands that the shares are not registered under the U.S. Securities Act of 1933.

SECTION 6 – SOUTH AFRICA INVESTOR CONFIRMATION

(Complete if resident in South Africa)

☐ I understand this offering may not constitute a public offer under South African law.
☐ I confirm that I am legally permitted to acquire private shares.
☐ I understand that regulatory approval for public listing is not guaranteed.

SECTION 7 – INTERNATIONAL INVESTORS

If resident outside the USA or South Africa:

☐ I confirm that participation in this share allocation does not violate laws in my jurisdiction.
☐ I am solely responsible for complying with my local securities and tax laws.
☐ I understand the Company has not made any representation regarding legal eligibility in my country.

SECTION 8 – SOURCE OF FUNDS

The Investor represents that:

☐ Funds used to purchase the Membership Package and shares are from lawful sources.
☐ The funds are not derived from criminal activity.
☐ I am not subject to sanctions or listed on any prohibited persons list.

The Investor understands that the Company may conduct AML and sanctions screening.

SECTION 9 – TAX RESPONSIBILITY

The Investor acknowledges that:

☐ I am solely responsible for any taxes arising from ownership of shares.
☐ The Company has not provided tax advice.
☐ I have been advised to seek independent financial and legal advice.

SECTION 10 – NO RELIANCE

The Investor confirms:

☐ I am not relying on any oral representations outside official written documents.
☐ I have reviewed the Shareholder Agreement.
☐ I understand the risks described in the Risk Disclosure documents.

SECTION 11 – ELECTRONIC ACCEPTANCE

By selecting “I Agree” during the online purchase process, the Investor:

  • Agrees to be legally bound by this Form

  • Confirms all statements are true and accurate

  • Authorizes compliance checks

  • Agrees to electronic record retention

INVESTOR DECLARATION

I hereby certify that all representations made in this Investor Eligibility & Representation Form are true and correct as of the date of acceptance.

Signature (Electronic): __________________________
Date: __________________________