Accredited Investor Registration Form

1. Information about yourself
* Denotes Required Field

*First Name:
*Last Name:
Middle Initial:
Title:
* Phone 1:	xxx-xxx-xxxx
Phone 2:	xxx-xxx-xxxx
Cell Phone:	xxx-xxx-xxxx
Fax:	xxx-xxx-xxxx
* Address 1:
Address 2:
* City:
* State:	* Zip:
Country:
* E-mail:
Alt E-mail:
This is an application for:

2. Investor Profile Information

Capital Available:
Minimum Capital Investment per Transaction:
Expected ROI: % return in

3. Accredited Investor Certification

I hereby acknowledge and certify that I am an Accredited Investor as defined by the United States and Exchange Commission's Regulation D, Rule 501, because (check all apply):
	My net worth, or joint net worth with my spouse, exceeds $1 million;
	My income has exceeded $200,000 in each of the two most recent years, or joint income with my spouse exceeded $300,000 in each year, and I (we) have a reasonable expectation of reaching the same income level in the current year;
	I am a principal or fiduciary of a bank as defined in section 3(a)(2) of the Securities Act of 1933, or a savings and loan association or other institution defined in section 3(a)(5)(A) of the same Act;
	I am a principal or fiduciary of a broker or dealer registered pursuant to section 15 of the Securities Exchange Act of 1934;
	I am a principal or fiduciary of an insurance company as defined in section 2(13) of the Securities Act of 1933;
	I am a principal or fiduciary of an investment company registered under the Investment Company Act of 1940, or business development company as defined in section 2(a)(48) of that Act;
	I am a principal or fiduciary of a Small Business Investment Company licensed by the U.S. Small Business Administration under section 301(c) or (d) of the Small Business Investment Act of 1959;
	I am a principal or fiduciary of a plan established and maintained by a state; its political subdivisions, or any agency or instrumentality of a state or its political subdivisions, for the benefit of its employees, if such plan has told assets in excess of $5 million.