Investor Interest Form

All information is kept strictly 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):

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mutual funds.Retirement account funds that must stay inside the retirement account.Retirement account funds that can be withdrawn from the retirement account.No funds available for investment within the next 30 to 60 days.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

First Name
Last Name
Year of Birth
Last 4 digits of SSN
Voter Registration State
Home Phone Number
Your Email
Business/Profession
Your Professional Title
Company Name
Employed Since
Business Address
Business Phone

(2) PREFERRED CORRESPONDENCE ADDRESSES:

HomeBusinessEmail

(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:
Cash Flow:

(4) RISK TOLERANCE

Please select the risk tolerance level appropriate for you.

Highly AggressiveSomewhat AggressiveModerateConservativeVery Conservative

(5) SPECULATION

Do your investment objectives allow for speculation? Please put an “X” next to the answer appropriate for you

No – NeverPossibly – Depending on the InvestmentYes

(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?

YesNo

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:

High SchoolSome CollegeBachelorMasterPhDDOMD

(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.

InvestmentsSalary, 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:

Your answers should total 100%

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

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) 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?

Yes, (a) is trueYes, both (a) and (b) are trueNo, 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 trueYes, both (a) and (b) are trueNo, 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.

For any questions or concerns, please contact 480-291-0251 ken.mcelroy@mccompanies.com