Model Accredited Investor Exemption Form Page 2
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4.
This Offering:
Price Per Security
Number of
Aggregate
Description of
Securities
Dollar
Security
to be
Amount
Offered
Debt
Equity (common
or preferred)
Convertible
Security
Partnership
Interests/Other
(Specify)
5.
Description of Business:
6.
Name of Broker-dealer who has solicited or intends to solicit purchasers in
this state.
_______________________________________________________________________________
Address: _____________________________________________________________________
_______________________________________________________________________________
By filing this Notice of Transaction, the Issuer of these securities hereby
represents that: (1) Sales of securities shall be made only to accredited investors
as defined in 17 CFR 230.501(a); (2) the Issuer is not an issuer in the development
stage that either has no specific business plan or purpose or has indicated that its
business plan is to engage in a merger or acquisition with an unidentified
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Parent category: Financial