All information is kept strictly confidential
All fields are required
Home Phone (optional)
Referred by (if applicable)
Please put a number from 1 through 4 next to each of the following to rank your investment objectives; 1 being the highest:
Please select the risk tolerance level appropriate for you.
Highly AggressiveSomewhat AggressiveModerateConservativeVery Conservative
Please select the answer most appropriate for you.
InvestmentsSalary, commissions or other regularly earned compensation
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
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 evaluating the merits and risks of any investmentI am using a financial advisor, planner, consultant, or some other advisor who has such knowledge and experience in financial and business matters that he/she is capable of evaluating the merits and risks of any investments
I acknowledge and warrant that I am an “accredited investor” for the following reasons:
(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 of my primary residence, provided the mortgages to not exceed the value of my primary residence
(b) My individual income was in excess of $200,000 in each of the past two years (excluding my spouse’s income) and I expect to have income (excluding my spouse’s income) in excess of that amount in the current year or my individual income for each such years together with my spouse’s is in excess of $300,000 each
Yes, (a) is trueYes, both (a) and (b) are true
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 firstname.lastname@example.org