Sophisticated Investor Questionnaire
This questionnaire may be completed electronically or you
may request a printed version to be mailed or faxed.
E-mail us your fax number or the
address you would like the hard copy sent to.
THIS QUESTIONNAIRE MUST BE COMPLETED AND DELIVERED TO
PURWOX (USA), INC. IN ORDER FOR YOU TO REGISTER AS A SOPHISTICATED INVESTOR
AND BE CONSIDERED AS A PROSPECTIVE PURCHASER OF SECURITIES IN PRIVATE
The purpose of this Questionnaire is to determine whether
you meet the standards for participation in a non-public offering under
Section 4(2) of the Securities Act of 1933, as amended ("Act"),
under Section 25102(f) of the California Corporate Securities Law of 1968, as
amended ("California Act"), and under the laws of other states. The
securities have not been and will not be registered with the Securities and
Exchange Commission under the Act or qualified with the California Department
of Corporations or with the securities agency of any other state. The shares
are being sold in reliance upon an exemption from the registration and
qualification requirements of the Act, the California Act, and other similar
Please complete as thoroughly as possible, sign, date, and
deliver this questionnaire to PURWOX (USA), Inc.
If the answer to any question is "None" or
"Not Applicable," please state so. Attach additional pages as
necessary to complete answers, where the space provided is insufficient.
Your answers will, at all times, be kept in the strictest
confidence; however, each individual who completes this Questionnaire hereby
agrees that PURWOX may present this Questionnaire to such parties as it deems
appropriate for verification in order to assure itself and future issuers that
the subsequent offer and sale of securities will not result in violation of
the registration provisions of the Act, the qualification provisions of the
California Act, or the provisions of other similar state laws.
Please print or type:
In order to verify the information provided, please provide
the name, address, telephone number and contact person for the following
2. Please describe your venture capital investments in the last three
3. The undersigned has previously purchased securities which were sold in
reliance on the non public offering exemption from registration under the Act:
If the answer is Yes, please list examples:
4. Please indicate the highest educational degree held by you:
5. Please describe your current employment and employer.
6. Please describe your principal business activities during the last five
7. Please evaluate your own ability to evaluate the merits and risks of
investing in securities of private issuers.
8. Please provide any additional information which would
evidence that you have sufficient knowledge and experience in financial and
business matters so that you are capable of evaluating the merits and risks of
investment in restricted securities of a private enterprise and could be
reasonably assumed to have the capacity to protect your own interests in
connection with the transaction. Attention should be directed to your
experience as an investor in securities, particularly investments in
securities for which no market exists. If you do not have sufficient knowledge
and experience in financial and business matters such that you are capable of
evaluating the merits and risks of investment in private securities, you are
urged to consult with one or more offeree representatives, i.e. professional
advisors, who do possess such knowledge and experience.
9. In evaluating the merits and risks of this investment, do you intend to
rely upon the advice of any professional advisor?
Any other person?
If Yes, then complete the following:
(i) My professional advisor (firm name):
(iii) Please describe the occasions in the last five years when you have
relied upon such person's advice:
(iv) Have you customarily compensated such person for his advice, either
specifically or by way of related professional services?
Please enter your name on the signature line and enter the
date in the space provided.
The foregoing statements are true and accurate to the best
of my knowledge and belief and I will promptly notify PURWOX (USA), Inc. of
any changes in the foregoing answers.
Do Not submit an application at this time.