Investor Application Form

Investor Information

Are you an accredited investor? *

You are an Accredited Investor if you have annual income in excess of $200,000 (or $300,000 joint income) for the last two years and expectation of the same for the current year, or household net worth in excess of $1 million, not including your primary residence.

We're sorry. This is a SEC registered Regulation D 506c offering – available to Accredited investors only.

If the undersigned Prospect is a partnership, corporation, limited liability partnership, trust or other entity the person executing this questionnaire represents and warrants to Company that he/she has the necessary power and authority.

Investor Legal Name *

First

Middle

Last

Investor Email Address *

Investor Phone Number *

Investor Primary Residence Address *

Address Line 1

Address Line 2

City

State

Zip Code

Spouse Legal Name (if applicable)

First

Middle

Last

Verifying Individual or Entity

In connection with the Investor’s intention to participate in securities offerings pursuant to Rule 506(c) under the Securities Act of 1933 (the “Securities Act”), the Verifying Individual or Entity below has taken reasonable steps to verify and has determined that Investor is an “accredited investor” as such term is defined in Rule 501 of the Securities Act, and hereby provides written confirmation of the following:

Do you wish to provide this information right away? *

Yes.
No, at a later time.

Name of Verifying Individual or Entity

Please include the name of an individual (i.e. CPA or Attorney) who can act as a Verifying Individual of your accreditation status.

Verifier Email Address

Verifier Phone Number

Verifying Individual or Entity qualifies as:

A broker-dealer registered with the Securities and Exchange Commission.
An investment advisor registered with the Securities and Exchange Commission.
A licensed attorney who is in good standing under the laws of the jurisdictions in which he or she is admitted to practice law.
A certified public accountant who is duly registered and in good standing under the laws of the place of his or her residence or principal office.

Verification

This written confirmation of Investor’s status as an “accredited investor” may be relied upon by any issuer and any of its partners, agents, affiliates, or participating platforms in connection with any transaction it may conduct pursuant to Rule 506 under the Securities Act. It may not be used or relied upon by an issuer or any other party for any other purpose.

Investor has qualified as an “accredited investor” because: *

he or she has earned income that exceeded $200,000 (or $300,000 together with a spouse) in each of the prior two years, and reasonably expects the same for the current year,
he or she has a net worth over $1 million, either alone or together with a spouse (excluding the value of the person’s primary residence).
the entity is a private business development company or an organization with assets exceeding $5 million.
Other

Please describe below – note it must comply with SEC Rule 501 *

This verification expires on

If left blank, the verification expires 90 days after the submission of this request.