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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 OFFERINGS.

INSTRUCTIONS:

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 state laws.

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:

Last Name
 First Name:
MI:
Date of Birth:
 E-Mail:
Occupation:
Residential Address:
City:
State:
Zip Code:

Business Information

Name

Business Address:

City:
 State:
Zip Code:

PART ONE

In order to verify the information provided, please provide the name, address, telephone number and contact person for the following firms:

Your Bank:
Contact:
Phone Number:
Your Accounting Firm:
Contact:
Phone Number:
Your Law Firm:
Contact:
Phone Number:
Your Stock Broker or Financial Advisor:
Contact:
Phone Number:
Your Trustee:
Phone Number:

PART TWO

2. Please describe your venture capital investments in the last three years.

3. The undersigned has previously purchased securities which were sold in reliance on the non public offering exemption from registration under the Act:
No
Yes

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 years.

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?

No
Yes

Any other person?

No
Yes

If Yes, then complete the following:

(i) My professional advisor (firm name):

Name:

Address:

(ii) Occupation

(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?

No
Yes

PART THREE

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.

Name:
Daytime Phone Number:
Date: City/State Signed In:

Do Not submit an application at this time.