2. PERSON COMPLETING THIS FORM a. Name: (First, Middle Initial, Last): ______________________________________________ b. Date of Birth: __________________ c. Home Address: ____________________________________________________________ d. State in which you are registered to vote: _________________ e. Home Telephone: _____-_______-__________ f. Cell Phone: _____-_______-__________ g. Email Address: ____________________________________________________________ h. Business/Profession: ________________________________________________________ i. Title: ____________________________________________ j. Company Name: ___________________________________ k. Employed Since: ____________________ l. Business Address: ___________________________________________________________ m. Business Telephone: ____-______-___________
3. CONTACT METHOD FOR COMMUNICATIONS. To which place would you prefer that communications be sent? ____ Home Address ____ Business Address ____Email Address ____ Other (please specify)________________________________________________
4. ENTITY INFORMATION. If you are submitting this form on behalf of an entity (corporation, limited liability company, etc), employee benefit plan or trust with assets of at least $5 million, please complete the following: a. Name of entity, plan or trust:_________________________________________________ b. Name of state where entity, plan or trust was formed: _______________ and check any of the following that apply: c._____ The undersigned is a corporation, partnership, business trust or charitable organization with assets in excess of $5 million that was not formed to acquire securities offered by the company presenting this questionnaire; d._____ The undersigned is a bank, a savings and loan association, a broke or dealer registered pursuant to Section 15 of the Securities Exchange Act of 19343, an insurance company, an investment company registered under the Investment Company Act of 1940, a business development company as defined in Section 2(a)(48) of that Act, a Small Business Investment Company licensed by the U.S. Small Business Administration under section 301(c) or (d) of the Small Business Investment Act of 1958, a private business development company as defined in Section 202(a)(22) of the Investment Advisors Act of 1940; e.______ The undersigned is an employee benefit plan a) either established and maintained by a government entity or governed by the Employee Retirement Income Security Act of 1974 (ERISA) and in either case with total assets in excess of $5 million, or b) governed by ERISA and where investment decisions are either made by a bank, savings and loan association, insurance company, or registered investment adviser or, if a self-directed plan, with investment decisions made solely by persons that are accredited investors; f._____ The undersigned is a trust with assets of at least $5 million, not formed to acquire securities offered by the company presenting this questionnaire, and whose purchases are directed by a sophisticated person who, either alone or with his/her independent purchaser representative, has such knowledge and experience in financial and business matters that he/she is capable of evaluating the merits and risks of a prospective investment.
If you have checked any of these items, please skip to the signature lines at the bottom.
g. Was your corporation, limited liability company, partnership, or other organization specifically formed for the purpose of acquiring securities offered by company presenting you with this questionnaire?
_____ Yes _____ No
If the answer is YES, each of the owners is your company will need to complete this questionnaire.
5. OVERALL INVESTMENT OBJECTIVES. Please rank your investment objectives from 1 through 4 in order of priority; 1 being the highest): _____Growth _____Current Income _____Tax Deferral _____Liquidity
7. SPECULATION. Do your investment objectives allow speculation? _____Yes ______No
8. ACCREDITED INVESTOR STATUS; please check every item that applies a._____ My net worth (either individually or with my spouse, if any), including home(s), investments and all property and other assets, is at least $1,000.000.
b._____ My individual annual income was at least $2000,000 in each of the two most recent years, and I expect such income in the current year.
c._____ My annual income, jointly with my spouse, was at least $3000,000 in each of the two most recent years, and I expect such income in the current year.
d._____ The undersigned is an entity and all of the entity's equity owners meet at least one of the three tests listed above.
e._____ The undersigned is a revocable trust created by the undersigned for his or her own benefit who meets at least one of the first three tests listed above. 9. QUALIFIED INVESTOR STATUS; please check every item that applies: a. _______I, either individually or jointly with my spouse, have a minimum net worth of two hundred fifty thousand dollars ($250,000) and had, during the immediately preceding tax year, gross income in excess of one hundred thousand dollars ($100,000) and reasonably expect gross income in excess of one hundred thousand dollars ($100,000) during the current tax year. I understand that for this purpose ?Net worth? excludes my and my spouse’s home, home furnishings, and automobiles, and other assets are valued at fair market value. b. _______ I, either individually or jointly with my spouse, have a minimum net worth of five hundred thousand dollars ($500,000). ?Net worth? must be determined exclusive of home, home furnishings, and automobiles. I understand that for this purpose ?Net worth? excludes my and my spouse’s home, home furnishings, and automobiles, and other assets are valued at fair market value.
10. EDUCATION. Please list your highest level of education and any degrees (including field if applicable) that you have received: ______________________________________________________________
12. JOB EXPERIENCE. Please briefly summarize any job experience that you have had that may show familiarity with business matters and/or investments: _____________________________________________________________________________________________ _____________________________________________________________________________________________
13. PRIMARY SOURCE OF INCOME:
_______ Investments _______Compensation
14. PRIOR INVESTMENT EXPERIENCE; please check all that apply: I have experience as an investor in:
_______ Stocks which are listed on a national securities exchange. _______ Mutual funds which hold a portfolio primarily consisting of stocks. _______ Taxable bonds or other debt instruments. _______ Tax exempt bonds. _______ Partnerships, limited liability companies, corporations which invest in real estate or real estate investment trusts (REITs). _______ Other types of investments not mentioned in any of the previous categories (please describe):
15. PORTFOLIO. Please estimate the percentage of your assets that you currently have in each category: _______% Stocks (including mutual funds) _______%Bonds _______% Certificates of Deposit/Loans/Savings Accounts _______% Principal Residence _______%Vacation Home(s) _______% Rental Property _______%Ownership of business(es) in which you are actively involved _______%Other 100% total
16. SOPHISTICATED INVESTOR STATUS; please check each item that applies:
_______ I have such knowledge and experience in financial, investment and business matters that I am capable of evaluating the merits and risks of any investments. _______ 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 this is checked, please complete the following:)
The name and contact information for this advisor is as follows: