Name*
Address / City / State / Zip*
Email*
Telephone*
1. Are you an "Accredited Investor," as defined below? Yes No
Between $0-$999,999.00 Between $1,000,000 and $1,500,000 Between $1,500,000 and $2,000,000 Between $2,000,00 and $5,000,000 Over $5,000,000
2. Do you also meet the Portfolio Requirement of a “Qualified Client” which means any natural person whose individual net worth, or joint net worth with that person's spouse, at the time of his purchase exceeds $2,000,000, excluding the value of your primary residence? * Yes No
3. In which industries do you prefer to invest?
*When calculating net worth, you should (i) exclude your primary residence as an asset, (ii) exclude debt secured by your primary residence, up to the fair market value of your residence, (iii) include the amount of any increase on the debt secured by your primary residence incurred within the last 60 days of making a purchase of the securities (unless related to the acquisition of your primary residence, and (iv) include debt in excess of the fair market value of your primary residence.
