CEO IQ Client Profile for Buyers/ Investors
For capital source representatives shopping for a company to invest in.
Note: Your information will remain confidential and will not be used for another purpose.

In order to obtain the necessary password to obtain access to the information for Businesses Seeking Capital, you must provide appropriate information to CEO IQ to confirm that you are an accredited investor (as defined by applicable United States Securities Laws).  To provide this information please answer the following questions.  By delivering this information, you represent and warrant to CEO IQ, and its officers, directors, employees, agents and owners, that the information is true and correct [if you answer affirmatively with respect to any of numbers 3 – 11, your affirmative answer shall constitute your representation and warranty to CEO IQ that you are reviewing the information provided in your representative capacity for the identified entity]:

Note: All fields except phone number are mandatory. Your information will not be used for any other purpose.
  Name:
  Company:
  Address:
  City:
  State:
  Zip Code:
  Email Address:
  Phone:
1. Are you a natural person whose individual net worth or joint net worth with your spouse, at this time, exceeds $1,000,000?

2. Are you a natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with your spouse in excess of $300,000 in each of those years, with a reasonable expectation of reaching the same income level in the current year?

3. Are you a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, and if so, with what company are you registered?

4. Are you an authorized representative of an investment company registered under the Investment Company Act of 1940, and if so, what is the name of this company?

5.Are you an authorized representative of a business development company as defined in Section 2(a)(48) of the Investment Company Act of 1940, and if so, what is the name of this company?

6.  Are you an authorized representative 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 1958, and if so, what is the name of this company?

7. Are you an authorized representative of a private business development company as defined in Section 202(a)(22) of the Investment Advisors Act of 1940, and if so, what is the name of this company?

8.  Are you an authorized representative of an organization: (a) described in Section 501(c)(3) of the Internal Revenue Code, (b) that was not formed for the specific purpose of acquiring any specific investment, and (c) that has total assets in excess of $5,000,000, and if so, what is the name of the organization?

9. Are you an authorized representative of an entity: (a) that is a corporation, Massachusetts or similar business trust, or partnership (whether a general partnership, joint venture or limited partnership), (b) that was not formed for the specific purpose of acquiring a specific investment, and (c) that has total assets in excess of $5,000,000, and if so, what is the name of the entity?

10. Are you an authorized representative of an entity: (a) that is a trust, (b) that has total assets in excess of $5,000,000, (c) that was not formed for the specific purpose of acquiring Units and (d) that the purchase by the undersigned is directed by a sophisticated person who, either alone or with his/her purchaser representative(s) (as such term is defined in Regulation D of the SEC), has such knowledge and experience in financial and business matters that he/she is capable of evaluating the merits and risks of investment in the Units, and if so, what is the name of the entity?

11.  Are you an authorized representative of an entity that is an entity in which all of the equity owners are accredited investors, and if so, what is the name of the entity? (If this item has been checked, you must have each of such equity owners execute and furnish a Certificate of Financial Position of Equity Owner in the form of Schedule 1 attached hereto.)

12. Is there any other basis under which you qualify as an accredited investor under Section 230.501 of Regulation D of the Securities Act of 1933, and if so, what is this basis?
 
CERTIFICATE OF FINANCIAL POSITION OF EQUITY OWNER

The undersigned represents and warrants to the Company that the undersigned is an accredited investor as described in the subparagraph checked below:

(a) A natural person whose individual worth or joint net worth with his/her spouse, at the time of his/her purchase, exceeds $1,000,000. OR

(b) A natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with that person's spouse in excess of $300,000 in each of those years and has a reasonable expectation of reaching the same income level in the current year. OR

(c) The undersigned is a bank as defined in Section 3(a)(2) of the Securities Act of 1933, as amended, or a savings and loan association or other institution as defined in Section 3(a)(5)(A) of such Act, whether acting in its individual or fiduciary capacity.OR

(d) The undersigned is a broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934. OR

(e) The undersigned is an insurance company as defined in Section 2(3) of the Securities Act of 1933, as amended. OR

(f) The undersigned is an investment company registered under the Investment Company Act of 1940. OR

(g) The undersigned is a business development company as defined in Section 2(a)(48) of the Investment Company Act of 1940. OR

(h) The undersigned is a small business investment company licensed to the U.S. Small Business Administration under Section 301(c) or (d) of the Small Business Investment Act of 1958. OR

(i) The undersigned is 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, and the undersigned has total assets in excess of $5,000,000. OR

(j) The undersigned is (a) an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974 and (b) the investment decision is made by a plan fiduciary, as defined in Section 3(21) of such Act, which is either a bank, savings and loan association, insurance company, or investment advisor registered under the Investment Advisors Act of 1940. OR

(k) The undersigned (a) is an employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974, (b) has total assets in excess of $5,000,000 or is a self-directed plan and (c) the investment decisions are made solely by persons that are accredited investors. OR

(l) The undersigned is a private business development company as defined in Section 202(a)(22) of the Investment Advisors Act of 1940. OR

(m) The undersigned (a) is an organization described in Section 501(c)(3) of the Internal Revenue Code, (b) was not formed for the specific purpose of acquiring Units, and (c) has total assets in excess of $5,000,000. OR

(n) The undersigned (a) is a corporation or similar business trust, or partnership (whether a general partnership, joint venture or limited partnership), (b) was not formed for the specific purpose of acquiring Units, and (c) has total assets in excess of $5,000,000. OR

(o) The undersigned (a) is a trust, (b) has total assets in excess of $5,000,000, (c) was not formed for the specific purpose of acquiring Units and (d) the purchase by the undersigned is directed by a sophisticated person who, either alone or with his/her purchaser representative(s) (as such term is defined in Regulation D of the SEC), has such knowledge and experience in financial and business matters that he/she is capable of evaluating the merits and risks of investments in the Units.

The undersigned will undertake to inform the Company immediately if this representation and warranty becomes untrue prior to the acceptance of the Subscriber's subscription or the Offering Termination Date, whichever shall first occur.

 
By selecting "submit" I verify that the all information above and options selected are true. I will receive a password from CEO IQ allowing me access to Capital Matchmaking oppportunities within 3 business days.