purchasers of Membership Units/Shares of Common Stock (the Shares) offered
by your company (the Company).
The Purpose of this Questionnaire is to solicit certain
information regarding your financial status to determine whether you are an
Accredited Investor, as defined under applicable federal and state
securities laws, and otherwise meet the suitability criteria established by the
Company for purchasing Shares. This
questionnaire is not an offer to sell securities.
Your answers will be kept as confidential as possible.
You agree, however, that this Questionnaire may be shown to such persons
as the Company deems appropriate to determine your eligibility as an Accredited
Investor or to ascertain your general suitability for investing in the Shares.
Please answer all questions
completely and execute the signature page
2. Address of Principal
3. Residence Telephone:
4. Where are you registered
5. Your drivers license
is issued by the following state:_________________
6. Other Residences or Contacts:
Please identify any other state where you own a residence, are registered
to vote, pay income taxes, hold a drivers license or have any other contacts,
and describe your connection with such state:
7. Please send all
(1)_____ Residence Address (as set forth in item A-2)
(2)_____ Business Address (as set forth in item B-1)
8. Date of
10. Social Security or Tax I.D.
Occupations and Income
(b) Business Telephone
2. Gross income during each
of the last two years exceeded:
3. Joint gross income with
spouse during each of the last two years exceeded $300,000
4. Estimated gross income
during current year exceeds:
5. Estimated joint gross
income with spouse during current year exceeds $300,000
1. 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, including the fair market value, less any mortgage,
of your principal residence.)
(4)_____$500,000-$750,000 (5)_____$750,000-$1,000,000 (6)_____over
2. 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:
Affiliation with the Company
Are you a director or executive officer of the Company?
Investment Percentage of Net Worth
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.
Prospective Investors Representations
The information contained in
this Questionnaire is true and complete, and the undersigned understands that
the Company and its counsel will rely on such information for the purpose of
complying with all applicable securities laws as discussed above.
The undersigned agrees to notify the Company promptly of any change in
the foregoing information which may occur prior to any purchase by the
undersigned of securities from the Company.
Signature (of joint purchase if purchase is to be
made as joint tenants or as tenants in common)