INVESTOR INTEREST FORM

INVESTOR INTEREST FORM

General Information

Address*

Yes
No

What are your overall investment objectives? Please put a number from 1 through 4 next to each of the following to rank your investment objectives; 1 being the highest:

Growth

Liquidity

Tax Deferral

Cash Flow

Investor Qualifications

Individual
Company

Certification of Sophisticated Investor Status

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 this is checked, please tell us the name and contact information for this advisor.)

ALL INVESTORS MUST CHECK AND FILL OUT 1 OF THE NEXT 3 AREAS:

Yes
No

My annual net income was at least $200,000 in each of the last two years, or my joint income with my spouse was in excess of $300,000 in each of those years; and I have reasonable expectation of income in the current year of at least equal to those amounts.

Yes
No

My current individual net worth or joint net worth with my spouse is at least $1 million (excluding home equity).

Business, Financial & Investment Experience  I am an experienced investor as demonstrated my following investment, business, and financial background:

Yes
No

Investment Funds Available  (Please check the most appropriate response)


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