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Purchaser Representative Questionnaire
PURCHASER REPRESENTATIVE QUESTIONNAIRE
Name of Company [Name of company]
Address of Company [Address of company]
Dear [Last Name of company representative]:
The information contained herein is being furnished to you in order to enable you to determine whether the undersigned may act as purchaser representative pursuant to Section 4.2 of the Securities Act of 1933, as amended, and Regulation D promulgated thereunder in connection with the proposed offer and sale of securities of the "Company".
[ Please attach additional sheets if required.]
1. Name: [Name]
Age: [Age]
Home Address: [Home Address]
Home Telephone Number: [Home Telephone Number]
2. My present occupation or position is as follows:
Firm Name: [Firm Name]
Nature of Business: [Nature of Business]
Position: [Position]
Nature of Duties: [Nature of Duties]
Business Address: [Business Address]
Business Telephone Number: [Business Telephone Number]
3. Any other prior occupations or positions I have held during the past five years:
4. I have had prior experience in advising clients with respect to the following types of investments:
a. Real Estate [Real Estate: Yes/No]
b. Oil and Gas [Oil and Gas: Yes/No]
c. Cattle [Cattle: Yes/No]
d. Other Tax Shelters. [Other Tax Shelters: Yes/No]
5. The professional licenses or registrations, including bar admissions, accounting certificates, real estate brokerage licenses, broker dealer or investment advisory registration, held by me are:
Check if License
License or or Registration
Registration Year Received is Still Effective
6.
a. Neither I nor any of my affiliates* now have or have had at any time since [two years previously], any material** relationship relationship with the Company or any of its affiliates and no such relationship is mutually understood to be contemplated, except: [Exceptions]
* The term "affiliate" of a person means a person that directly or indirectly, through one or more intermediaries, controls or is controlled by or is under common control with such person.
** The term "material", when used to modify "relationship", means any relationship that a reasonable investor might consider important in the making of the decision to acknowledge a person as his purchaser representative.
b. The amounts of compensation received or to be received as a result of the material relationship(s) described in Item 6.a, including any compensation received or to be received in connection with this transaction are: [Amounts of compensation]
Signature of Purchaser Representative Date