Who referred you? (Or who sent you an e-mail or letter with our website?)

Investor name(s) and home address:

I

GENERAL BACKGROUND AND INVESTMENT INFORMATION

If an investment opportunity became available within the next thirty to sixty days that interested you, would you have funds available for investment in (please check appropriate box or boxes):
Checking, savings, bank CDs or other bank deposits.
Stocks, bonds or mutual funds.
Retirement account funds that must stay inside the retirement account.
Retirement account funds that can be withdrawn from the retirement account.
No funds available for investment within the next 30 to 60 days.  I have completed the questionnaire, however.  Please check back in days.

(1)  PERSONAL BACKGROUND INFORMATION: 
a.  Last name, first name:

b.  Year of Birth: 

c.  Last 4 digits of Social Security Number: 

d.  State in which you are registered to vote:

e.  Home Telephone: 

f.  Cell Phone: 

g.  Email Address: 

h.  Business/Profession: 

i.    Your Professional Title

j.   Company Name: 

k.    Employed Since:

l.  Business Address: 

m.   Business Telephone: 

(2)  PREFERRED CORRESPONDENCE ADDRESSES: 
    Home:
    Business:
    Email:

(3) 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: Select a Number 1 2 3 4
     Liquidity: Select a Number 1 2 3 4
     Tax Deferral: Select a Number 1 2 3 4
     Current Income: Select a Number 1 2 3 4
         

(4)  RISK TOLERANCE. 
Please select the risk tolerance level appropriate for you.
     Highly Aggressive
     Somewhat Aggressive
     Moderate
     Conservative
     Very Conservative 

(5)  SPECULATION. 
Do your investment objectives allow for speculation?  Please put an “X” next to the answer appropriate for you
    No – Never
    Possibly – Depending on the Investment
    Yes 

(6)  PRIOR RELATIONSHIP WITH OFFERING COMPANY OR SPONSORS.  
Do you have a pre-existing personal or business relationship with the Company or any of its sponsors?
    Yes
    No
If yes, please briefly describe the nature of the relationship, including how long that relationship has existed.

(7)  EDUCATION. 
Please list your highest level of education and any degrees (including field if applicable) received:
 

(8)  LICENSES. 
Please list any job-related licenses that you now hold or have held in the past:
 

(9)  JOB EXPERIENCE. 
Please briefly summarize any job experience that you have had that may show familiarity with business matters and / or investments: 

(10)  PRIMARY SOURCE OF INCOME: 
Please select the answer most appropriate for you.
     Investments
     Salary, commissions or other regularly earned compensation 

(11)  PRIOR INVESTMENT EXPERIENCE
Please select all that apply:
Rentals and Real Property.
Stocks which are listed on a national securities exchange.
Mutual funds which hold a portfolio primarily of stocks.
Taxable bonds or other debt instruments.
Tax exempt bonds.
Partnerships, limited liability companies, corporations that invest in real estate or REITs.
Other types of investments not mentioned in the previous categories 

(12)  PORTFOLIO.
Please estimate the percentage of your assets currently held in each category and write it in next to that category:

% Cash, Savings and Money Market Accounts
% Principal Residence
% Vacation Home(s)
% Rental Property
% Stocks (including mutual funds)
% Bonds
% Loans payable to you or to companies you own and control
% Other
Your answers should total 100%

II

CERTIFICATION OF SOPHISTICATED INVESTOR STATUS
(Please check the box below that is true for you.)

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:)

III

CERTIFICATION OF ACCREDITED INVESTOR STATUS
(Please check the box below that is true for you.)

Are you a natural person who has either:

(a) an individual net worth exceeding one million dollars ($1,000,000.00) which may include home equity, furnishings, jewelry and other personal assets, or

(b) an individual income of at least $200,000.00 over the past two years which is expected to continue in the current year, or $300,000 with your spouse?

Yes, (a) is true
Yes, both (a) and (b) are true
No, neither (a) or (b) are true

CERTIFICATION OF NON-ACCREDITED INVESTOR STATUS, IF NEITHER OF ABOVE IS TRUE
(Please check the box below that is true for you.)

Are you a natural person who has either:

(a) an individual net worth of at least five times the investment amount you are considering, which may include home equity, furnishings and other personal assets, or

(b) an individual income of at least $60,000.00 over the past two years which is expected to continue in the current year?

Yes, (a) is true
Yes, both (a) and (b) are true
No, neither (a) or (b) are true

IV

INVESTMENT FUNDS AVAILABLE
(Please check the most appropriate responses.)

Should I choose at some point to make an investment with the company, the investment amount (range) I may have available would most likely be:
under $100,000
$100,000 to $500,000
$500,000 to $1,000,000
$1,000,000 or more

V

DATE AND SIGNATURE CONFIRMATION

I confirm, by typing my name in below and electronically submitting this form, that the information supplied herein is current and accurate.  I agree to sign a printed copy if asked to do so by recipient.    
Name: 

Please call Mr. Erickson at 619-275-3866, ext 209, or Mr. Dague at 800-811-2429, with any questions.
If you prefer to print, sign and mail or fax a copy of this form, please click here for a link to the form in
PDF format and follow instructions to either fax or mail it in.  Thank you.