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, sign
(enter full name), date, and deliver
this questionnaire to Fordham Financial
Management electronically.
If the answer
to any question is "None" or "Not
Applicable," please so state.
Attach additional pages as necessary
to complete your answers where
the space provided on this form
is insufficient.
Your answers will,
at all times, be kept strictly
confidential; however, each individual
who completes this Questionnaire
hereby agrees that to 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. |