Prospective Investor Questionnaire
 

Name:
 

Address:
 

Email Address:
 

Telephone:
 

Fax:
 

Primary Contact:
 

Nature of Investor:
 

If Other Specify:
 

Investment Interest
 

Transaction Size:
 

Investment Amount:
 

Industry:
 

If Other Specify:
 

By completing and submitting this form, the Prospective Investor represents that such investor is an "accredited investor" (as defined in Regulation D under the Securities Act of 1933, as amended), a "qualified client" (within the meaning of Rule 205-3 under the Investment Advisers Act of 1940, as amended) or a "qualified purchaser" (as defined in the Investment Company Act of 1940, as amended).