All information kept stricty confidential.

Who referred you?

Your name 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):





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:


(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:
Liquidity:
Tax Deferral:
Cashflow:

(4) RISK TOLERANCE
Please select the risk tolerance level appropriate for you.




(5) SPECULATION
Do your investment objectives allow for speculation? Please put an "X" next to the answer appropriate for you


(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?


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.

(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.)




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) my individual net worth, along with the net worth of my spouse, exceeds $1,000,000, excluding the value of my personal residence and excluding from my liabilities the mortgages on my personal residence, provided the mortgages to not exceed the value of my personal residence; 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?



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?




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:




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: