Model Accredited Investor Exemption Form Page 3
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company or companies, or other entity or person; and (3) the Issuer reasonably
believes that all purchasers are purchasing for investment and not with the view
to or for sale in connection with a distribution of the security. Any resale of a
security sold in reliance on this exemption within 12 months of sale, except a
resale to an accredited investor or pursuant to a registration statement effective
under applicable state securities law, shall be presumed to be with a view to
distribution and not for investment. Securities issued under this exemption may
only be resold pursuant to registration or an exemption under applicable state
securities law.
The undersigned represents that the Issuer is familiar with the conditions that
must be satisfied to be entitled to the Accredited Investor Exemption of the state
in which this notice is filed and understands that the Issuer claiming the
availability of this exemption has the burden of establishing that these conditions
have been satisfied.
The Issuer has read this notification and knows the contents to be true and has
duly caused this notice to be signed on its behalf by the undersigned duly
authorized person.
Issuer (Print or type): _____________________________________________________________
Signature: _________________________________________________________________________
Name (Print or type): ______________________________________________________________
Title (Print or type): _______________________________________________________________
Date: _______________________________________________________________________________
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