Address:

City:

State:

Zip code:

Telephone (plus area code):

Email Address:

Market Position:
$10,000 - $20,000$20,000 - $50,000$50,000 - $100,000$100,000 - $500,000500,000 - $1,000,000$1,000,000 and up

Investment Criteria:
Conservative Moderate Risk

One of the following questions must be answered in the affirmative to qualify as a purchaser:

I have had an individual income in excess of $200,000 in each of the two most recent years and reasonably expect an individual income in excess of $200,000 in the current year.

My spouse and I have had a joint income in the excess of $300,000 in each of the two most recent past years and we reasonably expect a joint income of $300,000 in the current year.

I have an individual net worth or joint net worth with my spouse in excess of $1,000,000.

I have read the required disclaimer and the foregoing statements are true and accurate to the best of my information and belief and I will promptly notify IPO-Merge.com of any changes in the foregoing answers.