I am a(n):(Required)

For Individual Investors

Name
Address
Date of Birth
Are you a U.S. Citizen?

For Investors that are Corporations, Partnerships, Trusts, or other Entities

Name of Corporation, Partnership, Trust, or Other Entity
Address of Principle Office
Date of Incorporation or Organization
Name and Title of Authorized Individual to Execute the Questionnaire
Please list name and percentage of ownership. One name per line.

For All Investors

Is the undersigned an officer or director of a publicly-held company?
I ______ personally invested in investments sold by means of private placements within the past five years.
Do you consider yourself to have such knowledge and experience in financial and business matters to enable yourself to evaluate the merits and risks of investment in the Company?
Listed below are the categories of accredited investors, as defined by Regulation D, promulgated under the Securities Act of 1933, as amended. Please check the appropriate space provided below if the Investor falls within one or more of these categories.
Please indicate whether you intend to have an attorney, accountant, investment advisor or other consultant act as its Purchaser Representative in connection with this investment
If yes, please list below the name, business address and telephone number of the person who is your purchaser representative.
Address of Representative
If the undersigned utilizes a Purchaser Representative, the Purchaser Representative will be required to complete a questionnaire to be supplied by the Company.

Gross Income

If the undersigned is an individual. was your personal income from all sources for the previous calendar year more than (check the HIGHEST number applicable for each year.)
2022 (Projected)
2021
2020

Net Worth

If the undersigned is an entity which checked item (8) under Paragraph 3(f) above in reliance upon the accredited investor categories set forth in items 1 and 2 of Paragraph 3(f), please state the name, address, total personal income from all sources for the previous calendar year, and the net worth (exclusive of home, furnishings, and personal automobiles) for each equity owner of said entity.

Investor Acknowledgement

The Investor hereby certifies that the information contained herein is complete and accurate and the Investor will notify the Company promptly of any change of information. Specifically, the Investor hereby certifies that the information contained above concerning the residency of the Investor is true and correct. The Investor realizes and understands that, but for the truth of the information contained herein, the Investor would not receive consideration by the Company pertaining to this investment. If the Questionnaire is completed on behalf of a corporation, partnership, trust, or estate, I, the person executing on behalf of the Investor, represent that I have the authority to execute and deliver the Questionnaire on behalf of such corporation, partnership, trust, or estate.
Date

Signature for Corporation, Partnership, Trust, or other Entity

Signature for Individual Investor

Digital Signature

By checking this box, you agree and understand that using an "electronic signature" is legal and binding. By filling in the field labeled "Signature," you are agreeing that all the information given is to the best of your abilities true.(Required)