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 1. General Information — to be completed by all potential investors
For Trusts, Corporate, or Company potential investors, the following questions should be
completed with regard to the individuals making the investment decision.
1. Name: ________________________________
3. Contact Information:
Business Phone: _______________________________
Mobile Phone: _________________________________
Home Phone: _________________________________
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:
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: _____________________
T.I.N. and /or E.I.N. of Business: ________________________________
State of Business: ________________________________
Legal form of entity (please circle one):
Corporation General Partnership Limited Partnership Limited Liability Corporation
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 piece of paper, 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 2. Accredited Investor- to be completed by accredited investors
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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.
_______ An investment company registered under the Investment Company Act of 1940 or a
business development company as defined in section 2(a)(48) of that Act.
_______ A Small Business Investment Company licensed by the U.S. Small Business
Administration under section 301(c) or (d) of the Small Business Investment Act of 1958.
_______ A plan established and maintained by a state, its political subdivisions, or any agency or
instrumentality of a state or its political subdivisions, for the benefit of its employees, if such
plan has total assets in excess of $5,000,000.
_______ An employee benefit plan within the meaning of the Employee Retirement Income
Security Act of 1974, if the investment decision is made by a plan fiduciary, as defined in section
3(21) of such act, which is either a bank, savings and loan association, insurance company, or
registered investment adviser, or if the employee benefit plan has total assets in excess of
$5,000,000 or, if a self-directed plan, with investment decisions made solely by persons that are
_______ A private business development company as defined in section 202(a)(22) of the
Investment Advisers Act of 1940.
_______ An organization described in section 501(c)(3) of the Internal Revenue Code,
corporation, Massachusetts or similar business trust, or partnership, not formed for the specific
purpose of acquiring the securities offered, with total assets in excess of $5,000,000.
_______ A director, executive officer, or general partner of the issuer of the securities being
offered or sold, or any director, executive officer, or general partner of a general partner of that
_______ A natural person whose individual net worth, or joint net worth with that person's
spouse, at the time of his purchase exceeds $1,000,000.
_______ A natural person who had an individual income in excess of $200,000 in each of the
two most recent years or joint income with that person's spouse in excess of $300,000 in each of
those years and has a reasonable expectation of reaching the same income level in the current
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_______ A trust, with total assets in excess of $5,000,000, not formed for the specific purpose of
acquiring the securities offered, whose purchase is directed by a sophisticated person as
described in Rule 506(b)(2)(ii).
_______ An entity in which all of the equity owners are accredited investors as defined by Rule
501 of Regulation D of the Securities Act of 1933.
The undersigned hereby certifies that the above and foregoing answers are true and complete to
the best of his or her knowledge, information, and belief.
Printed Name: _____________________________
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