Information on investment opportunities are provided to accredited investors only. Please complete the form below to request information on available opportunities. This form generally takes 3 to 5 minutes to complete.


All information is kept strictly confidential.

Who referred you:

Checking, savings, bank CDs or other bank depositsStocks, bonds or mutual fundsRetirement account funds that must stay inside the retirement accountRetirement account funds that can be withdrawn from the retirement accountNo funds available for investment within the next 30 to 60 days.

(1) PERSONAL BACKGROUND INFORMATION:

a. Last name, first name:

b. Email:

c. Year of Birth:

d. Last 4 digits of Social Security Number:

e. State in which you are registered to vote:

f. Home Telephone:

g. Cell Phone:

h. Your home address:

i. Business/Profession:

j. Your Professional Title:

k. Company Name:

l. Employed Since:

m. Business Address:

n. Business Telephone:

(2) PREFERRED CORRESPONDENCE ADDRESSES:

HomeBusinessEmail

(3) OVERALL INVESTMENT OBJECTIVES

Please put a number from 1 through 4 next to each of the following to rank your investment objectives:

< Lowest 1----------2----------3----------4 Highest >

Growth:
Liquidity:
Tax Deferral:
Cashflow:

(4) RISK TOLERANCE

Please select the risk tolerance level appropriate for you.

Highly AggressiveSomewhat AggressiveModerateConservativeVery Conservative

(5) SPECULATION

Do your investment objectives allow for speculation? Please put an “X” next to the answer appropriate for you

No – NeverPossibly – Depending on the InvestmentYes

(6) PRIOR RELATIONSHIP WITH OFFERING COMPANY OR SPONSORS

Do you have a pre-existing personal or business relationship with the Company or any of its sponsors?

YesNo

If yes, please briefly describe the nature of the relationship, including how long that relationship has existed:

(7) EDUCATION

Please list your highest level of education and any degrees (including field if applicable) received:

High SchoolSome CollegeBachelorMasterPhDDOMD

Field:

(8) LICENSES

Please list any job-related licenses that you now hold or have held in the past:

(9) JOB EXPERIENCE

Please briefly summarize any job experience that you have had that may show familiarity with business matters and / or investments:

(10) PRIMARY SOURCE OF INCOME:

Please select the answer most appropriate for you.

InvestmentsSalary, commissions or other regularly earned compensation

(11) PRIOR INVESTMENT EXPERIENCE

Please select all that apply:

Rentals and Real Property.Stocks which are listed on a national securities exchange.Mutual funds which hold a portfolio primarily of stocks.Taxable bonds or other debt instruments.Tax exempt bonds.Partnerships, limited liability companies, corporations that invest in real estate or REITs.Other types of investments not mentioned in the previous categories

(12) PORTFOLIO

Please estimate the percentage of your assets currently held in each category and write it in next to that category:

% Cash, Savings and Money Market Accounts

% Principal Residence

% Vacation Home(s)

% Rental Property

% Stocks (including mutual funds)


% Bonds

% Loans payable to you or to companies you own and control

% Other

Your answers should total 100%

I have such knowledge and experience in financial, investment and business matters that I am capable of valuating the merits and risks of any investment.I am using a financial advisor, planner, or consultant, or some other advisor who has such knowledge and experience in financial and business matters that he/she/it is capable of evaluating the merits and risks of any investments.


If you use a financial advisor, please tell us the name and contact information for this advisor:

Are you a natural person who has either:

(a) my individual net worth, along with the net worth of my spouse, exceeds $1,000,000, excluding the value of my personal residence and excluding from my liabilities the mortgages on my personal residence, provided the mortgages to not exceed the value of my personal residence;

or

(b) an individual income of at least $200,000.00 over the past two years which is expected to continue in the current year, or $300,000 with your spouse?

Yes, (a) is trueYes, (b) is trueYes, both (a) and (b) are trueNo, neither (a) or (b) are true






CERTIFICATION OF NON-ACCREDITED INVESTOR STATUS, IF NEITHER OF ABOVE IS TRUE

(Please check the box below that is true for you.)

Are you a natural person who has either:

(a) an individual net worth of at least five times the investment amount you are considering, which may include home equity, furnishings and other personal assets, or

(b) an individual income of at least $60,000.00 over the past two years which is expected to continue in the current year?



Yes, (a) is trueYes, (b) is trueYes, both (a) and (b) are trueNo, neither (a) or (b) are true