l0

c3 Fo' oll'craius n!- l

ThisMedicalcertificateis to be completedin-English by a regjsteredmed,calpractitioner.pleasesupplyadditionatdetajls

on a separatesheetif necessary'one fofm for each p€rson (includingchilclren)is Io oe compJeted.
practrt,oner
mustaskfor evidenceof identiflcation Nole that the medrcal
(suci as a passportoilD cardll iee secrrons A and D of thisform.

41 Surnameorfahily namo as shown n passporl 42. Fnst orsiv.n nam€(s)asshowrin passporl

A3. Place and country ol binh

D Mate t) Fenate
Da, Manth
49. lD/passpo.tdetaits issuingcounrryand tO/passpon
number

The lvledical
Examineris requestedto ask the followingquestionsof to reviewthem if they havebeenansweredpreviously
Givedetails(if necessaryon an attachedsh€er)and datesif any oflhe qu€stionsberoware answeredwith
ves

e1o, Ooyou cur.entlyhaveany serioushealthprobtems? B yes D No

a l l . Haveyou b€enbospitatisedin th6 tasttive y€a6? O y6s tr No

412.Haveyou visiteda doctor in the t6stlhreeyea.sotherthanaorroutinech.ck_uDs? Dyes trjro-

lEl3. D" you surf.; ". hM yo ? tryA tr,!o I

Br4 uo vou sufier o. h.ve vou eversuff€r.d trom atos or atDs reratedcondtuon"o."ny i--u* a"r.i*y "y.a.o.""2 tr Yes flNo

B15. Do you sufio.or haveyo" e"er sun"reffi

The Medical Examiner is requestedto examine lhe applicant generally and to answer the following queslions.
Give detaits
and dates if any oflhe questionsbelow are answered wilh yes.

cl7. Heighr(incm)
 -Anysigns or abnormalities.
c20. Cardiova6cularsystom tn"rraingpriia bro;;;;;r-, h;;,1., tr Yes

C21.Digestiveorgans
andabdomen-Anysignsotabnomatities?
!yes tr/Vo

Urogenilalorgam- Anysqns ofabnomalihes?

NeruoussFtom and *n 30 organs- Anysisnsor abnormatiries?

tryes trNo

C24 ML,sculoskeletal
sysr6m Aly sg4s of abnormal'ties?OYej trNo

C25. Endocrine5ystem Anysignsolabnomatilies,inctoding

lhyrctd? tryes trl/o

E y€s O No
C25. various A.yothersignsor abnormalities?

lmportant:You mustencloseoriginal resultsof an HIV (AIDS)test showingcleariyfirst nameand surname.Notelhat the

HIVlestresultsmustbe not older than 3 months.

D28. Full name of n6dlc.l dafiinor

029,Organizarion

D32.terephone dnber
'-t
I heroby conlim th.t I h € id.ntifi.d, quostlon.d and.l.mlncd th. .ppllc.6i .nd haw aBwer.d .ll qm.tlon. to th. b6!t of my kntutedge

Slanp and signatureof mediel examiner

 C4

Governm€nt of St. Kitts E Nevis

fh s lnvesimentConfirmationand EscrowAgreementform is to be completedin English by the main applicantonly.Famr/y

mernberswho apply together should be mentioned in seclron B on th s fofm and the toial nvestment amounl should be
calculated (field88 and sectionC).
and slatedon thisform accordingly

A 1 S u r n a m e o r t a m inl ya m ea s s h o w nr p a s s p o r t t; First o.givcn name(s) as shown n passpo.l

,A3 Place and counrry ol birth

D Mate

8 6 . L i s t a l l f a n i l y m e m b e r sw h o a p p l y t o g € l h e r w i t hy o u u n d € r r n e s a m e a p p l i c a t i o n

A 7 T o l a l n u m b e ro f d e p e n d a n l s ss.r.r"r,"q;;J n*r*;"..,"t

Pleasecalculatelhe total required investment amount. which includesall governmeni/processrngfees, accordrnglo the
fo krwingschedule:

{)Single applicant.US$ 200,000

BrApp cantwith up to threefamily members ire. one spouseand lwo chidrenbelowlhe alle of 18):US$ 250.000
 I herewthoonfrrmthat I wil rrrevocabty Inveslthe arnountof USg
1 4 l - ,I ln I ' p l ' r 8 8o l l r ' \ I n n ' a i d I o n l l r b u l r o n l o r h e S u q d r I n d u s l r v D r v e r s r f r c a r o n r o u n d " t , o , B " * " i " ; , ; ; i ' ; l ;
.r'
Ths contrrbulron rs irrevocable except/n the case citizenship wouldnot be granted,i.e the contnbuton is condilonaioniyon
a posrtrve decisionby lhe Govefnmentof Sl Kitts& Nevisto grantcitzenshipto me and the personstistedin fietd
88 ol lhrs

herewth agreelo pay. irrevocably and immediately

upon signingof this form,the totatamountas specrfied
aboveinto lhe
SIDFescrowat Bank oi Nova Scoiiain St Kitts,as specifedunAerseclionE. paymenl Inslructons.L understand
that lhis
escfowaccounlis an accounlopenedand operaledunderthe supervison of the Ministryof Financeol St. Kitts& Nevis
[,1y
lundsthal I have placedin that accountand that lhave been coniirmedto be investeduilderthe CitizenshrD.bv Investme;t
Programof St Kitts& Neviswil be held in lhat accountpendingthe decisionof lhe Governmentwhethe;or not lo grant
cilzenshrpio me (afd myfamily if applicable)lunderstandthat no rnierestis paidwhileihe flnds are held in escrow:and
rroextra lecs or costs are due elthef

lf c tizenshrp
is granled,my fundswill immediatety
be pardout.

i c tizenships nol granted.for whateverreason.my fundswi I rmmediately

be returnedto me, exceptUSg 3 500 per person
(16 yearsor older)lnc Lrdedin the appiication,
whichwrllbe payableto the covernmentio covercedainexoensesretaledio
lhe processrng of my applcaton

t no decisionis made by the Governmentof St. Kitts & Nevis, my flnds will be kept in escrow unlil 4 nronlhs ffom the date
my applrcaironwas received by the Government.Thereafter,if no decrsion is made by the covernmenl, ali funds wi be
mmedralely returnedto me. exceptUS$ 3,500 per person(16 yearsof older) includeclin the applcatton,which witl be
payabe to lhe Govefnmentlo covercertainexpensesrelatedto the processing of my app tcauon.

ThrsAgreementshallbe governedand conslruedIn accordancewith substaniiveSl Kitts& Nevis tawonly withoutgiving

effect to its confl|ct-of-/awsrules All dispules, whether of conlractualor other nalure, arising out of or rn connectionwilh lhis
Aqreemenlor otherwlsen connectonwith my application,includingdtspuieson questionsof conclusion,bindinqefiect
amendmenlsand lermination,shall be resolved-to the exclusionof the ordinary courts, bv a sole Arbttralor The
proceedrngs. includlngthe appointmentof the sole Arbitrator,shall be conducledunder tne Rutes of Arbrtrahonof the
niernatonal Chamber of Commefce. The seal of the Tribunal shal be Basselerre,St Kitis and the language lo be usecirn
lhe pfoceedrngs shallbe Englsh The decisionof the ArbitralTribunatsha be finat.

expressy agreeand confrm thal I and the personsIncludedin thrsapplication

will not, underany circumstances.
takeanv
ega acllonor commenceproceedlngs of any kind againstihe Govefnrnent
ofSl Kitts& Nevisof any of agentsengagedto
provrdeservrceslo me, excepl providedin this Agreemenl

tulorespeclically I expresslyagree and contrrmthai I ancithe personsincludedin this app icationwil not at anv trmeor for
any reasoniake legalactlonor commenceproceedings of any kindagainsilhe Governmentof St. Kitts& Nevisor any of ils
allentsor assocratedor af{lliatedpai(ies,in any courl or wth any adm nistrativebody or agency in lhe UnttedStjles of
Anrerica (USA) | expressy waive any rights to take legal action or commence proceedings of any krnd against the
Governmentof St. Krtts & Nevs or any of its agents engaged to provideserviceslo me, n anv court or wtth anv
dd I n .trdt,!*bodyo- agen,y ot rha.,SA

ThrsAgreementshall come into force upon me signrngbe ow. I agree that no signatureor olher confirrnationis requiredfrom
the Governrnenlof St. Kilts & Nevis to constitutethe validityof ths Agree;ent. and I undefstandihat bv olaono mv
s.rnalurebelowlhrsAgreemeftwjll come inlo tut{force

S g f . t u r e o r m a i na p p h . a n r
 \\

in us rundsasspecified
above
rniorhesrDFEscrow
Account
;ffiil;:ln::::f ;X:nt accordjns
io rherorowins
bank

Payto:
JPMorganChaseBankN.A
153West151st
Street
4lh Floor
New York,NY 1O019
USA

ABA Number:021000021

SWIFT:CHASUS33

Chips ABA; 0002

For credit to:

Ban\ ol NovdScotia(SLotrabanh) St.K,trsandNevrs
FortStreer
Bassetere
St. Kitts
Federationof St. Kills & Nevis

Transil#: 94235

For final credit to:

AccountName SIDFEscrow(SKN)

51368481

lmportanl - Please Read Carefully

You musl make sure lhat

yon include your complete name as reference

with lhe payment,so that your paymenrcan oe property
recorded rhe paymenl may be made from an accounrother
yourLomo'etenrrre mLstappearas ,eleren(ewtth than an accounron your personarname. but
the wire Irnster
lhe full amount is,credited free of any charges, i e you
should inslruct your bank to cover a lranster
cnarges.Includ.no lhe chargesof correspondirgba^Fsand the recrprent binr<
you enctose with this form a copy of the payment
confirmalion from your bank, showrngthat the
paymenr nas oeen made and all relevantbank charges
have been oaid.