3LB Accredited Investor Offeree Questionnaire and Certifications
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Occupation (Including Title)
Education (Highest Level Completed)
Net Worth
$5M or more
$1M to $5M
Less than $1M
Gross Income (Average for last 2 years)
$300k or more
$200k-$300k
Less than $200k
Is this income combined with that of your spouse?
Yes
No
Do you expect a similar level of income this year?
Yes
No
I utilize the services of the following attorney, accountant or other advisor to assist me in analyzing investment opportunities (include name/occupation/email):
Name of vesting entity:
Type of entity:
Individual
Trust
LLC/Corporation
IRA
Other
Certifications
I am an “accredited investor” as defined in Rule501(a) of Securities and Exchange Commission Regulation D
Yes
No
I have adequate means of providing my currentneeds, and possible personal contingencies, and have no need for liquidity inan investment in the Company
Yes
No
I, together with my advisors, have specificknowledge and experience in related financial and business matters so as to becapable of evaluating the relative economic and operational merits and risks ofan investment in the stock.
Yes
No
I hereby certify that I have answered theforegoing questions to the best of my knowledge and that my answers hereto arecomplete and accurate.
Yes
No
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: