Residential & Commercial Real Estate Services

Please Fill Out This Form And Submit It

First Name :
Last Name :
Spouse First & Last Name :
Business Partner's First & Last Name (please ask your Business Partner to fill out a separate form) :
Business Name :
Website :
Email :
Business Phone: :
Fax: :
Home Phone: :
Cell: :
Address :
City :
State :
Zip Code :

I certify that I am an "Accredited Investor" within the meaning of Rule 501 of Regulation D promulgated under the Securities Act of 1933 as I fall under one or more of the following catagories:

Check all that apply:

1. : Any of the following as defined in the Securities Exchange Act of 1934: any bank / any savings and loan association / any registered broker or dealer / any insurance company / any registered investment company / any business development company / any small business investment company licensed by the U.S. Small Business Administration / any plan established and maintained by a state / any employee benefit plan / any self-directed plan
2. : Any private business development company as defined in section 202(a)(22) of the Investment Advisers Act of 1940
3. : Any organization described in section 501(c)(3) of the Internal Revenue Code-corporation- Massachusetts or similar business trust or partnership not formed for the specific purpose of acquiring the securities offered- with total assets in excess of $5 Million
4. : a director / executive officer / or general partner of the issuer of the securities being offered or sold - or any director-executive officer or general partner of a general partner of that issuer
5. : a natural person who has individual net worth or joint net worth with a spouse exceeds $1 Million not including their primary residence
6. : a natural person with income exceeding $200000 in each of the two most recent years or joint income with a spouse exceeding $300000 for those years and a reasonable expectation of the same income level in the current year
7. : a trust with assets in excess of $5 Million and not formed to acquire the securities offered and whose purchase is directed by a sophisticated person as described in the Act
8. : Any entity in which all of the equity owners are accredited investors
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