| Contact Information |
| |
|
| First Name * |
|
| Last Name * |
|
| Company |
|
| Email * |
|
| Address * |
|
| Address Continued |
|
| City * |
|
| State * |
|
| Zip Code * |
|
| Fax |
|
| Best Tel # * |
|
| Alt Phone# |
|
| |
|
| Question or Comment |
| |
|
| Question/Comment |
|
| |
|
| Other Information |
| |
How Do You Know Us? *
|
|
If Referred, Who Referred You?
|
| Funds Available to Invest (Include Cash & Non-Cash Accounts) *
|
| |
| Miscellaneous |
| |
| At least 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 joint income in the excess of $300,000 in each of the two most recent past years and we reasonably expect joint income of $300,000 or more in the current year. |
|
I have an individual net worth or joint net worth with my spouse in excess of $1,000,000. |
At Least One of the Above Income or Net Worth Statements Is Answered Affirmatively with a "Yes".
(Check Your Email for Private Placement Details.) |
|
I have read the required disclaimer (click here) and the foregoing statements are true and accurate to the best of my information and belief and I will promptly notify Private Label Equities, LLC of any changes in the foregoing answers.
|