For Investors that are Corporations, Partnerships, Trusts, or other Entities
Name of Corporation, Partnership, Trust, or Other Entity
Address of Principle Office
Address Line 2
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -- District of Columbia Puerto Rico Guam American Samoa U.S. Virgin Islands Northern Mariana Islands
State of Incorporation or Organization
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -- District of Columbia Puerto Rico Guam American Samoa U.S. Virgin Islands Northern Mariana Islands 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 I ______ personally invested in investments sold by means of private placements within the past five years.
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?
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
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.
Signature for Corporation, Partnership, Trust, or other Entity
Name of Investor
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.