Investor Intake

Investor's Name

First

Last

Investor's Email

Investor's Phone

State of Residency

Investment Amount

3rd-Party the Size

Investor Type

Individual
Co-Investors
Entity

Enter the name that will appear on the capital funding transfer

Use your full name for Individual investors. If investing as an Entity, provide the legal name. Spouses that are Co-Investors should include each party's first and last names.

Verification method (third-party verification preferred)

Third-Party
Self Verification

3rd-party verification letter must be completed by one of the following: your registered broker-dealer, your registered investment adviser, your licensed attorney in good standing, your certified public accountant (CPA) in good standing Self-verification: Accredited Investor Questionnaire Includes supporting Net Worth or Income documents as defined in Exhibit II – Page 6 of the Private Placement Memorandum

Shirt Size

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