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Potential Investor Screening Checklist and Questionnaire

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					This Potential Investor Screening Checklist and Questionnaire is used to determine
whether a potential investor meets the standards for participation in a nonpublic offering
under various federal and state securities laws. The document collects general
information about the individual, business entity or trust investors. It also asks whether
the potential investor meets the standards of an accredited investor under Regulation D
of the Securities Act of 1933. The Act provides companies with a number of exemptions
to sell its securities to accredited investors. This document should be used by a
company that offers or sells its securities.
                  Potential Investor Screening Checklist and Questionnaire

The information provided will be used to determine whether you meet the standards for
participation in a nonpublic offering under Section 4(2) of the Securities Act of 1933 and various
state securities laws. The information you provide will be treated confidentially. However, you
agree that the information may be released to appropriate parties as provided by law.

SECTION I General Information – to be completed by all potential investors

For potential trust, corporate or company investors, the following questions should be
completed with regard to the individuals making the investment decision.

1.     Name: ________________________________

2.     Address:
             Business: ________________________________________

               Residence: _______________________________________

3.     Contact Information:

               Business Phone: _______________________________

               Mobile Phone: _________________________________

               Home Phone: _________________________________

               Email: _______________________________________

4.     Personal Information (to be completed by individual investors):

               Date of Birth: ______________________________

               Marital Status (please circle one): Married Divorced Single Widowed

               Social Security Number: _________________________________

5.     Employment Information:

               Employer: _______________________________________

               Nature/Type of Business: ______________________________

               Position Held: _______________________________________

               Dates Employed: _____________________________________
6.      Business Entity Information (to be completed by investors who are a business entity):

                Date of organization or incorporation: _____________________

                TIN and /or EIN of Business: ________________________________

                Principle state of business: ________________________________

                Legal form of entity (please circle one):
                Corporation General Partnership Limited Partnership           LLC


7.      Trust Information (to be completed by investors who are a trust):

                Revocable trust (If the trust does not have $5 million in assets or if the trust was
                specifically formed for the purpose of this investment, identify each grantor and
                indicate under what circumstances the trust is revocable by the grantor. Also
                indicate the category that describes how each such grantor is qualified as an
                Accredited Investor):
                __________________________________________________________________
                __________________________________________________________________
                __________________________________________________________________
                (Continue on a separate sheet, if necessary.)

                Other type of trust (indicate type of trust and, for trusts other than pension trusts,
                name the grantors and beneficiaries):
                __________________________________________________________________
                __________________________________________________________________
                __________________________________________________________________
                (Continue on a separate piece of paper, if necessary.)

SECTION II Accredited Investor- to be completed by accredited investors

I certify that I meet the Accredited Investor condition(s), as defined by Rule 501 of Regulation D
of the Securities Act of 1933, set forth below by initialing the applicable box.

______ A bank as defined in section 3(a)(2) of the Act, or any savings and loan association or
other institution as defined in section 3(a)(5)(A) of the Act whether acting in its individual or
fiduciary capacity; any broker or dealer registered pursuant to section 15 of the Securities
Exchange Act of 1934.

_______ An insurance company as defined in section 2(a)(13) of the Act.




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Description: This Potential Investor Screening Checklist and Questionnaire is used to determine whether a potential investor meets the standards for participation in a nonpublic offering under various federal and state securities laws. The document collects general information about the individual, business entity or trust investors. It also asks whether the potential investor meets the standards of an accredited investor under Regulation D of the Securities Act of 1933. The Act provides companies with a number of exemptions to sell its securities to accredited investors. This document should be used by a company that offers or sells its securities.