Investor Questionnaire

Complete the Questionnaire for consideration as an Investor.

I am a(n):*
- Individual Investor
- Corporation, Partnership, Trust, or other Entity
For Individual Investors
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Date of Birth
Are you a U.S. Citizen?
- Yes
- No
College
How did you hear about us?
Business/Employer Name
Nature of Business Employment
Occupations or Duties
Please set forth other prior occupations or duties during the past five years
Year of Anticipated Retirement
For Investors that are Corporations, Partnerships, Trusts, or other Entities
Name

Name of Corporation, Partnership, Trust, or Other Entity
Office Phone
Address of Principle Office
Street Address Address Line 2 City State ZIP Code
State of Incorporation or Organization
Date of Incorporation or Organization
Taxpayer Identification Number
Nature of Business
Name and Title

Name and Title of Authorized Individual to Execute the Questionnaire
Name of record and beneficial owners of entity (10% ownership or more)
Please list name and percentage of ownership. One name per line.
For All Investors
Relationship to the Company or Manager of the Company
Is the undersigned an officer or director of a publicly-held company?
- Yes
- No
If yes, please specify
I ______ personally invested in investments sold by means of private placements within the past five years.
- have
- have not
Please list all investments made during the past five years (include dates, nature, and amounts of investment)
Do you consider yourself to have such knowledge and experience in financial and business matters to enable yourself to evaluate the merits and risks of investment in the Company?
- Yes
- No
If yes, please set forth the basis for your answer (e.g. investment or business experience, profession, past review of other investment offerings, etc.)
Listed below are the categories of accredited investors, as defined by Regulation D, promulgated under the Securities Act of 1933, as amended. Please check the appropriate space provided below if the Investor falls within one or more of these categories.
- Any natural person whose individual net worth or joint net worth with that person's spouse, at the time of his purchase, exceeds $1,000,000. Net worth includes homes, furnishings and automobiles.
- Any natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with that person's spouse in excess of $300,000 in each of those years and has a reasonable expectation of reaching the same income level in the current year.
- A bank, insurance company, registered investment company, employee benefit plan if the investment decision is made by a bank, insurance company or registered investment adviser, or an employee benefit plan with more than $5 million of assets.
- Any private business development company as defined in Section 202(a) (22) of the Investment Advisers Act of 1940.
- Any organization described in Section 501(c)(3) of the Internal Revenue Code, corporation, Massachusetts or similar business trust, or partnership, not formed for the specific purpose or acquiring the securities offered, with total assets in excess of $5,000,000.
- Any director, executive officer or general partner of the issuer of the securities being offered or sold, or any director, executive officer or general partner of a general partner of that issuer.
- Any trust with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the securities offered, whose purchase is directed by a sophisticated person as described in Rule 506(b)(2)(ii).
- Any entity in which all of the equity owners are accredited investors.
- The Investor does not qualify in any accredited category as indicated above.
Please indicate whether you intend to have an attorney, accountant, investment advisor or other consultant act as its Purchaser Representative in connection with this investment
- Yes
- No
If yes, please list below the name, business address and telephone number of the person who is your purchaser representative.
Representative Name
Firm
Phone
Address of Representative
Street Address Address Line 2 City State ZIP Code
If the undersigned utilizes a Purchaser Representative, the Purchaser Representative will be required to complete a questionnaire to be supplied by the Company.
Gross Income
If the undersigned is an individual. was your personal income from all sources for the previous calendar year more than (check the HIGHEST number applicable for each year.)
2019 Projected
- $150,000
- $200,000
- $250,000
2018
- $150,000
- $200,000
- $250,000
2017
- $150,000
- $200,000
- $250,000
Net Worth
My estimated liquid assets equal:
My estimated non-liquid assets equal:
Entities
If the undersigned is an entity which checked item (8) under Paragraph 3(f) above in reliance upon the accredited investor categories set forth in items 1 and 2 of Paragraph 3(f), please state the name, address, total personal income from all sources for the previous calendar year, and the net worth (exclusive of home, furnishings, and personal automobiles) for each equity owner of said entity.
Investor Acknowledgement
The Investor hereby certifies that the information contained herein is complete and accurate and the Investor will notify the Company promptly of any change of information. Specifically, the Investor hereby certifies that the information contained above concerning the residency of the Investor is true and correct. The Investor realizes and understands that, but for the truth of the information contained herein, the Investor would not receive consideration by the Company pertaining to this investment. If the Questionnaire is completed on behalf of a corporation, partnership, trust, or estate, I, the person executing on behalf of the Investor, represent that I have the authority to execute and deliver the Questionnaire on behalf of such corporation, partnership, trust, or estate.
Date
Signature for Corporation, Partnership, Trust, or other Entity
Name of Investor
By
Signature
Name
Title
Signature for Individual Investor
Signature
Name
Signature of Joint Investor
Name of Joint Investor
Digital Signature
By checking this box, you agree and understand that using an "electronic signature" is legal and binding. By filling in the field labeled "Signature," you are agreeing that all the information given is to the best of your abilities true.*
- I agree

For Individual Investors

For Investors that are Corporations, Partnerships, Trusts, or other Entities

For All Investors

Gross Income

Net Worth

Investor Acknowledgement

Signature for Corporation, Partnership, Trust, or other Entity

Signature for Individual Investor

Digital Signature