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Investor Suitability Questionnaire

To gain access and review our qualified investor and portfolio information, we’re requesting you to complete an investor suitability questionnaire form.

Once your application has been verified, we may approve your investor account and our capital placement relationship will begin.

Address of Principal Residence:

Mailing Address (Complete only if different from residence)

Residence Telephone:

Where are you registered to vote?:

Your driver’s license is issued by the following state:

Other Residences or Contacts: Please identify any other state where you own a residence, are registered to vote, pay income taxes, hold a driver’s license or have any other contacts, and describe your connection with such state:

Please send all correspondence to:

Date of Birth:

Citizenship:

Social Security or Tax I.D. #:

Name of Employer:

Occupation:

Business Address:

Business Telephone Number:

Facsimile:

Gross income during each of the last two years exceeded:

Joint gross income with spouse during each of the last two years exceeded $300,000:

Estimated gross income during current year exceeds:

Estimated joint gross income with spouse during current year exceeds $300,000:

Upload Driver's License:

Upload 2 Year's Tax Return:

Current net worth or joint net worth with spouse (note that “net worth” includes all of the assets owned by you and your spouse in excess of total liabilities, excluding the value of your primary residence.):

Current value of liquid assets (cash, freely marketable securities, cash surrender value of life insurance policies, and other items easily convertible into cash) is sufficient to provide for current needs and possible personal contingencies:

Are you a director or executive officer of the Company?:

If you expect to invest at least $150,000 in Shares, does your total purchase price exceed 10% of your net worth at the time of sale, or joint net worth with your spouse.:

Is this investment consistent with your overall investment strategy?:

Accountant First Name:

Accountant Last Name:

Email:

Phone:

Leave this empty:

Your legal name

Your email address