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Accredited Investor Questionnaire [Company] Inc

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Form of Accredited Investor Questionnaire

for a [COMPANY]Offering

Please provide the following information to [COMPANY]to allow [COMPANY]to comply with the requirements of the , as amended.Securities Act of 1933

By signing below, the prospective investor indicates his/her/its understanding that [COMPANY]will rely on the information provided below for compliance purposes.

The undersigned hereby represents and warrants to [COMPANY]that the information contained in this Accredited Investor Questionnaire is true, complete and accurate.

The undersigned agrees to notify [COMPANY]promptly of any changes in the information provided below prior to making any investment.

1. Prospective Investor Information

If the prospective investor is not an individual, please provide the information listed in Section 1.A. below with respect to the person making the investment decision on behalf of the organization. If the prospective investor is an individual, please provide the information listed in Section 1.B. below.

1.A. Non-Individual Prospective Investor

1) Please provide the name of the prospective investor:__________________________________

2) Please provide the form of ownership for the prospective investor:

⃞  Partnership

⃞  Limited Liability Company

⃞  Corporation

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Accredited Investor Questionnaire [Company] Inc

Investment Agreements -- US - General