| | MAIL TO: | | | EMAIL* TO: | | | FAX TO: | |
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NB PRIVATE MARKETS ACCESS FUND LLC
c/o UMB Fund Services, Inc. 235 W. Galena St. Milwaukee, WI 53212 |
| | aiprocessing@umb.com | | |
FAX: (816) 860-3140
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| | Account #: | | | | |
| | Full Account Registration Line 1: | | | | |
| | Full Account Registration Line 2: | | | | |
| | Address: | | | | |
| | City, State, Zip: | | | | |
| | Social Security # or Taxpayer ID #: | | | | |
| | Telephone Number: | | | | |
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| | Advisor Account #: | | | | |
| | Advisor Name: | | | | |
| | Advisor Address Line 1 | | | | |
| | Advisor Address Line 2 | | | | |
| | Advisor Telephone Number: | | | | |
| | FOR CUSTODIAL ACCOUNTS ONLY (IRA, 401k, ETC.) | | |||
| | Custodial Account #: | | | | |
| | Custodian Name: | | | | |
| | Custodian Address: | | | | |
| | Custodian City, State, Zip: | | | | |
| | Custodian Telephone Number: | | | | |
| | Bank Name: | | | | |
| | ABA Routing Number: | | | | |
| | For Credit to: | | | | |
| | Name(s) on Bank Account: | | | | |
| | Bank Account Number: | | | | |
| | For Further Credit to: | | | | |
| | Name(s) on Shareholder’s Account: | | | | |
| | Shareholder Account Number at Broker: | | | | |
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Print Name of Authorized Signatory (and Title if applicable)
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Print Name of Authorized Signatory (and Title if applicable)
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| | Signature | | |
Print Name of Authorized Signatory (and Title if applicable)
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