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ACCREDITED INVESTOR REGISTRATION
 

THIS QUESTIONNAIRE MUST BE COMPLETED AND DELIVERED TO FORDHAM FINANCIAL MANAGEMENT IN ORDER FOR YOU TO REGISTER AS AN ACCREDITED INVESTOR AND BE CONSIDERED AS A PROSPECTIVE PURCHASER OF SECURITIES IN PRIVATE OFFERINGS


INSTRUCTIONS:
The purpose of this Questionnaire is to determine whether you meet the standards for participation in a non-public offering under Section 4(2) of the Securities Act of 1933, as amended ("Act"), under Section 25102(f) of the California Corporate Securities Law of 1968, as amended ("California Act"), and under the laws of other states. The securities have not been and will not be registered with the Securities and Exchange Commission under the Act or qualified with the California Department of Corporations or with the securities agency of any other state. The shares are being sold in reliance upon an exemption from the registration and qualification requirements of the Act, the California Act, and other similar state laws.

Please complete as thoroughly as possible, date, and deliver this Questionnaire to Fordham Financial Management .

If the answer to any question is "None" or "Not Applicable," please so state.

Your answers will, at all times, be kept strictly confidential; however, each individual who completes this Questionnaire hereby agrees that Fordham Financial Management may present this Questionnaire to such parties as it deems appropriate for verification in order to assure itself and future issuers that the subsequent offer and sale of securities will not result in violation of the registration provisions of the Act, the qualification provisions of the California Act, or the provisions of other similar state laws.
 

 

PART ONE

*Last Name: *Middle Initial: *First Name:
Age: Date of Birth:  
 
*Occupation:
*Residential Address:
*City: *State: *Zip Code:
*Business Address:
*City: *State: *Zip Code:
*Your E-mail Address:

 

PART TWO

 Please provide the following information:
..Are you :
*(i)

A self-directed employee benefit plan, with investment decisions made solely by persons that are accredited investors?

 Yes

 No
*(ii)

A natural person whose individual net worth, or joint net worth with such person's spouse, exceeds $1,000,000?

 Yes

 No
*(iii)

A natural person who had an individual income in excess of $200,000 in each of the two most recent calendar years and has a reasonable expectation of reaching the same income level in the current year?

 Yes

No
*(iv)

A natural person who had joint income with your spouse in excess of $300,000 in each of the two most recent calendar years and has a reasonable expectation of reaching the same income level in the current year?

 Yes
 No
*(v)

 A natural person who had an individual adjusted gross income as shown on your federal income tax return in excess of $200,000 in each of the two most recent calendar years and has a reasonable expectation of reaching the same income level in the current year?

 Yes
 No
*(vi)

A natural person who had joint adjusted gross income with your spouse as shown on your federal income tax return in excess of $300,000 in each of the two most recent calendar years and has a reasonable expectation of reaching the same income level in the current year?

 Yes
No
*(vii) 

Any trust, with total assets in excess of $5,000,000, whose purchase of securities is directed by a sophisticated person has with such knowledge and experience in financial and business matters that such person is capable of evaluating the merits and risks of any prospective investment?

 Yes
No
*(viii)

An organization described in Section 501(c)(3) of the Internal Revenue Code, corporation, Massachusetts or similar business trust, or partnership with total assets in excess of $5,000,000?

 Yes
No
*(ix)

A bank as defined in section 3(a)(2) of the Securities Act of 1933 ("Act"), a savings and loan association or other institution as defined in section 3(a)(5)(A) of the Act whether acting in its individual or fiduciary capacity.

 Yes
No
*(x)

Any broker or dealer registered pursuant to section 15 of the Securities Exchange Act of 1934.

 Yes
No
*(xi)

An insurance company as defined in section 2(13) of the Act.

 Yes
No
*(xii )

An investment company registered under the Investment Company Act of 1940 or a business development company as defined in section 2(a)(48) of that Act.

 Yes
No
*(xiii)

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.

 Yes
No
*(xiv)

A plan established and maintained by a state, its political subdivisions, or an agency or instrumentality of a state or its political subdivisions for the benefit of its employees, if such plan has total assets in excess of $5,000,000.

 Yes
No
*(xv)

An employee benefit plan within the meaning of the Employee Retirement Income Security Act of 1974 if 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 registered investment adviser, or if the employee benefit plan has total assets in excess of $5,000,000 or, if a self-directed plan, with investment decisions made solely by persons that are accredited investors?

 Yes
No


PART THREE
 

Please forward information about private placements by email. I understand the minimum investment in these Private Placements is $30,000

I am interested in Hedge Funds I understand the minimum investment in Hedge Funds is between $250,000 & $5,000,000.

   
The foregoing statements are true and accurate to the best of my information and belief and I will promptly notify Fordham Financial Management of any changes in the foregoing answers.
*E-mail Address:
*Daytime Phone Number:

Private Fax Number:

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