Who referred you to us?

Your name:

Your home address:

This is not a binding commitment on my part.  The dollar amount I/we may consider investing within the next sixty (60) days would most likely be in the range of: $ to $

Please contact me/us when the company has sufficient potential funds to acquire its assets.  If I choose to invest I understand the investment itself is sold only by prospectus.  I have been provided a copy or electronic access to it.  I understand I should read it carefully before investing, and that the Company has the right to reject any investment, in whole or in part.

The source of funds would most likely be (please check appropriate box or boxes):

Checking, savings, bank CDs or other bank deposits.
Stocks, bonds or mutual funds.
Trust funds, business account funds or other sources.
Retirement account funds that can be withdrawn from the retirement account
Retirement account funds that stay inside the retirement account to avoid a tax penalty.  (This is done with a Self-Directed retirement account - contact Company for details.)

REQUIRED CONTACT INFORMATION:

Cell phone:

Work phone:

Home phone:

e-mail:

Last 4 digits of Social Security Number (helps us match this up with Investor Questionnaire):

I/we 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. 
Signature:

Signature: