Investor Agreement Page 2
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1
2Please complete all sections.
Investment Amount: ($1,000 minimum) $
, (in words)
Dollars.
Investment Term:
1 year
3 years
5 years
7 years
10 years
Interest Rate:
0%
.5%
1%
1.5%
2%
5-10 year terms may also select:
2.5%
3%
Interest Payments (for multi-year investments only):
reinvested
paid out annually - anniversary of investment.
If you would like to have your interest payments sent to an alternative address, please indicate this on a cover sheet.
Number of Signature(s) Required to Alter or Amend This Agreement: (for joint investments only)
one
two.
Activity Statements: If you would like annual statements showing account activity and balance, please check here:
.
I have an account manager who would like copies of statements or correspondence and I have indicated my
specific desires on a cover sheet.
Taxpayer ID Number: Please enter the Investor’s taxpayer identification number or social security number below.
For joint investments, parties filing joint tax returns may use either social security number.
Social Security/Tax ID #:
Social Security/Tax ID #:
Name:
Name:
Under penalty of perjury, the Investor certifies that: (1) This is my correct taxpayer identification number, and (2) I
am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been
notified by the Internal Revenue Service that I am subject to backup withholding as a result of failure to report all
interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, (3) I am a U.S.
person (including a U.S. resident alien), and (4) I am a resident of North Carolina.
Certification Instructions: You must cross out item (2) above if you have been notified by the IRS that you are
currently subject to backup withholding because you failed to report all interest and dividends on your tax return. See
IRS Form W-9 for further instructions.
Donation: (optional) I would like to make a tax-deductible donation. Please find enclosed a check for:
$500
$250
$100
$50
other $
.
Please tell us how you heard about Mountain BizWorks: _______
Investor(s):
Signature:
Date:
Print Name:
Title:
(if Investor is an entity)
Signature:
Date:
Print Name:
Title:
(if Investor is an entity)
Please return this signed and completed form with a check for (a) the investment amount and (b) any
donation to: Mountain BizWorks, Attn: Development Department, 153 South Lexington Avenue, Asheville, NC
28801.
*************************************************************************************
ACCEPTED:
DATE RECEIVED BY MOUNTAIN BIZWORKS AND
MOUNTAIN BIZWORKS
EFFECTIVE DATE OF THIS AGREEMENT:
By:
Name: Shaw Canale Its: Chief Executive Officer
2
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