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Registration

1.  Information about yourself:
       Name:    
       Title:    
       Business or Organization:    
       Phone:    
       Fax:    
       Mailing Address:    
       City:    
       State:    
       Zip Code:    
       E-mail:    
       This is an application for:     New Registration Renewal Registration

        I currently belong to to the

        following investment

        organization:

    
 
2.  Accredited Investor Certifications:
  My net worth, or joint net worth with my spouse, exceeds $1 million;
  My income has exceeded $200,000 in each of the two most recent years, or joint income with my spouse exceeded $300,000 in each year, and I (we) have a reasonable expectation of reaching the same income level in the current year;
  I am a principal of fiduciary of a bank as defined in section 3(a)(2) of the Securities Act of 1933, or a savings and loan association or other institution defined in section 3(a)(5)(A) of the same Act;
  I am a principal or fiduciary of a broker or dealer registered pursuant to section 15 of the Securities Exchange Act of 1934;
  I am a principal or fiduciary of an insurance company as defined in section 2(13) of the Securities Act of 1933;
  I am a principal or fiduciary of an investment company registered under the Investment Company Act of 1940, or business development company as defined in section 2(a)(48) of that Act;
  I am a principal or fiduciary of a Small Business Investment Company licensed by the U.S. Small Business Administration under section 301(c) or (d) of the Small Business Investment Act of 1959;
  I am a principal or fiduciary of a plan established and maintained by a state; its political subdivisions, or any agency or instrumentality of a state or its political subdivisions, for the benefit of its employees, if such plan has told assets in excess of $5 million.

       

       

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