Investor Statement Form - State Of Illinos
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1
2
3Illinois Secretary of State
Securities Department
Jefferson Terrace, Ste. 300 A, 300 W. Jefferson St.
Investor Statement
Springfield, IL 62702 • 217-782-2256
69 W. Washington St., Ste. 1220
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Chicago, IL 60602 • 312-793-3384
800-628-7937
By completing this statement you will be assisting the Illinois Securities Department with the inquiry of a Company, Dealer, Investment Advisor, etc.
The information received will enable the Securities Department to conduct a more accurate inquiry.
INVESTOR INFORMATION:
Name:
Age:
Address:
City:
State:
ZIP:
Home Telephone Number:
Work Telephone Number:
Please indicate the most convenient day to be contacted:
❏ Monday
❏ Tuesday
❏ Wednesday
❏ Thursday
❏ Friday
Please indicate the most convenient time and place to be contacted:
❏ Work (indicate time):
❏ Home (indicate time):
INQUIRY REFERENCE TO:
Name (Company, Firm/Dealer, Investment Advisor, Operator, Driller or Individual):
Address:
City:
County:
State:
ZIP:
Name, Title/Position, Address and Telephone Number of first person you dealt with:
CONTACT INFORMATION:
Did you know the person who contacted you prior to the sale?
❏ Yes
❏ No
Did the salesperson come to your home?
❏ Yes
❏ No
Did to go to the firm’s place of business?
❏ Yes
❏ No
Did you meet the salesperson away from the firm’s place of business (such as a convention, your business, restaurant or other location)?
❏ Yes (indicate other location):
❏ No
Printed by authority of the State of Illinois. May 2005 — 100 — SEC 318
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