Investor Form | Value Investment Group

Who referred you?

First and Last Name:*

City & State

I. GENERAL BACKGROUND AND INVESTMENT INFORMATION

If an investment opportunity became available within the next 30 to 60 days that interested you, would you have the funds available for investments in (please check appropriate box or boxes):

Checking, savings, bank CDs or other bank deposits.
Stocks, bonds or mutual funds.
Retirement account funds that must stay inside the retirement account.
Retirement account funds that can be withdrawn from the retirement account.
No funds available for investment within the next 30 to 60 days.

Year of Birth:

Email Address:*

Primary Phone:*

Secondary Phone:

Business/Profession:

Your Professional Title:

Company Name:

Employed Since:

Preferred Correspondence Addresses:

Primary
Secondary
Email

Please select the risk tolerance level appropriate for you.

Do your investment objectives allow for speculation?

No
Possibly – Depending on the Investment
Yes

Do you have a pre-existing personal or business relationship with the Company or any of its sponsors?

Yes
No

If yes, please briefly describe the nature of the relationship, including how long that relationship has existed.

Please briefly summarize any job experience that you have had that may show familiarity with business matters and/or investments.

What is your primary source of income? Please select the answer most appropriate for you.

Investments
Salary, commissions or other regularly earned compensation

Please tell us about your prior investment experience. Select all that apply.

Rentals and Real Property
Stocks which are listed on a national securities exchange
Mutual funds which hold a portfolio primarily of stocks
Taxable bonds or other debt instruments
Tax exempt bonds
Partnerships, limited liability companies, corporations that invest in real estate or REITs
Other types of investments not mentioned in the previous categories

Please estimate the percentage of your assets currently held in each category and write it in below that category. Your answers should total 100%.

(1) Cash, Savings, and Money Market Accounts:

(2) Principal Residence

(3) Vacation Home(s)

(4) Rental Property

(5) Stocks (including mutual funds)

(6) Bonds

(7) Loans payable to you or to companies you own and control

(8) Other

CERTIFICATION OF SOPHISTICATED INVESTOR STATUS

Please select which choice below is true for you.

I have such knowledge and experience in financial, investment and business matters that I am capable of evaluating the merits and risks of any investment.
I am using a financial adviser, planner, consultant, or some other adviser who has such knowledge and experience in financial and business matters that he/she is capable of evaluating the merits and risks of any investments. (If this is selected, please tell us the name and contact information for this adviser.)

Name and Contact Information for advisor

CERTIFICATION OF ACCREDITED INVESTOR STATUS

Are you a natural person who has either: (A) my individual net worth, along with the net worth of my spouse, exceeds $1,000,000, excluding the value of my personal residence and excluding from my liabilities the mortgages on my personal residence, provided the mortgages do not exceed the value of my personal residence, or (B) my individual income has been at least $200,000 over the past two years which is expected to continue in the current year, or $300,000 with your spouse? (Please select the option that is true for you.)

Yes, (A) is true
Yes, (B) is true
Yes, both (A) and (B) are true
No, neither (A) nor (B) are true

If neither of the above are true, please tell us if you are a natural person who has either: (A) an individual net worth of at least five time the investment amount you are considering, which may include home equity, furnishing, and other personal assets, or (B) and individual income of at least $60,000.00 over the past two years which is expected to continue in the current year?

Yes, (A) is true
Yes, (B) is true
Yes, both (A) and (B) are true
No, neither (A) nor (B) are true

INVESTMENT FUNDS AVAILABLE

Should I choose at some point to make an investment with the company, the investment amount (range) I may have available would most likely be:

Under $100,000
$100,000 to $500,000
$500,000 to $1,000,000
$1,000,000 or more

DATE AND SIGNATURE CONFIRMATION

I confirm, by typing my name in below and electronically submitting this form, that the information supplied herein is current and accurate. I agree to sign a printed copy if asked to do so by recipient.