Instructions

PLEASE ANSWER EACH OF THE FOLLOWING QUESTIONS. If you do not do so, we can not serve you the requested information.

We will, subject to a number of exceptions, keep the information you provide in response to the following questions confidential. Click here to see more information about our privacy policy.

General Information

Please supply the following general information about yourself or the organization that you represent.

1. Name:
   

2. Street Address:
   

3. Phone Number:
   

4. Fax Number:
   

5. E-mail Address:
   
   
   

   Accredited Investor Status—Individual Investors

6. Are you married
   Yes   No

Financial Information

Please answer each of the following questions in U.S. dollars.

Your Net Worth

For the purpose of this question, "net worth" includes the estimated fair market value of your assets, including your residence, net of the amount of your debt, including any debt secured by your assets.

7. What is your individual net worth?
   

8. What is your net worth with your spouse? (Please skip this question if your answer was "No" for question 6.)
   

   Your Income

   For the purpose of these questions, "income" includes salary, bonuses and other earned income, as well as other types of income, such as dividends, interest, rents, and royalties.

9. What was your income in the past two calendar years?

   Last year:
   
   Year before last:
   
   

10. What income do you expect to make in the current calendar year?
    

11. What was your spouse's income in the past two calendar years?

    Last year:
    
    Year before last:
    
    

12. What income does your spouse expect to make in the current calendar year?
    

Representations

I hereby represent that all the information supplied herein is true, correct and complete as of the date hereof. If I am granted any information (the "Information") I agree (1) to notify you immediately of any material change in the foregoing answers and (2) not to provide the said Information to anyone other than my spouse, lawyers, accountants or other professional advisers. I acknowledge that you do not provide me with investment advice.

	Please click here if you accept the terms of the electronically delivered privacy policy agree to the representations listed above and wish to submit your responses to the preceding questions to us.
	Please click here if you do not wish to submit your responses to the preceding questions to us or do not agree to the representations listed above.

Representations

I hereby represent that all the information supplied herein is true, correct and complete as of the date hereof. I hereby represent that I am authorized by the organization on whose behalf I am acting (the "Organization") to request information (the "Information"). I agree on behalf of the Organization (1) to notify you immediately of any material change in the foregoing answers and (2) not to share the Information with anyone other than the Organization's lawyers, accountants or other professional advisers. I acknowledge that you do not provide me or the Organization with investment advice.

	Please click here if you agree to the representations listed above and wish to submit your responses to the preceding questions to us.
	Please click here if you do not wish to submit your responses to the preceding questions to us.