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Prescient Venture Partners, LLC
CONFIDENTIAL ACCREDITED INVESTOR QUESTIONNAIRE & NEW ACCOUNT FORM
Prescient Venture Partners, LLC
(the "Company") from time to time offers interests in investment entities
to accredited investors pursuant to Regulation D promulgated under the
Securities Act of 1933, as amended (the "Act"). The purpose of this
questionnaire is to provide information to the Company concerning the
suitability of prospective purchasers under the Act and any applicable
state securities laws and to qualify investors to obtain information
concerning certain offerings via the Company's website.
This questionnaire should be completed by
those who wish to be added to the Company's confidential client mailing
list based on their interest in becoming a purchaser of securities that
have not been and will not be registered with the Securities and Exchange
Commission under the Act or with the securities authorities of any state.
If the answer to any question is "None"
or "Not Applicable," please so state.
PLEASE PRINT THIS DOCUMENT. WHEN
DONE, USE THIS "BACK BUTTON"
TO RETURN TO PREVIOUS PRESCIENT VENTURE
PARTNERS, LLC'S WEBSITE.
| I. |
BACKGROUND INFORMATION |
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NAME: |
________________________________________________ |
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DATE OF BIRTH: |
________________________________________________ |
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MARITAL STATUS: |
________________________________________________ |
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SPOUSE'S NAME: |
________________________________________________ |
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RESIDENTIAL ADDRESS: |
________________________________________________ |
| |
|
________________________________________________ |
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RESIDENCE TELEPHONE NUMBER: |
(______)________________________________________ |
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FACSIMILE NUMBER: |
(______)________________________________________ |
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E-MAIL ADDRESS: |
________________________________________________ |
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SOCIAL SECURITY NUMBER: |
________________________________________________ |
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NAME OF EMPLOYER: |
________________________________________________ |
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POSITION: |
________________________________________________ |
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BUSINESS ADDRESS: |
________________________________________________ |
| |
|
________________________________________________ |
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BUSINESS TELEPHONE NUMBER: |
(______)________________________________________ |
Please describe your employment positions or occupations during the last
five years (listing the inclusive dates of each) indicating any and all
employment related experience in financial and business matters.
| |
Employment, Position
or Occupation |
Nature of Duties |
From: |
To: |
| (1) |
_________________________________________________________________ |
| |
_________________________________________________________________ |
| (2) |
_________________________________________________________________ |
| |
_________________________________________________________________ |
Are you employed by or associated with a Member of the NASD or a publicly
traded company? ___Yes ___No
If Yes, provide name of Member, address of contact person and phone
number:
________________________________________________________________
| II. |
ACCREDITED INVESTOR REPRESENTATIONS |
| 1. |
Do you or your spouse have a combined net worth of $1 million or
more?
____No ____Yes |
| 2. |
For each of the past two years has your annual income been greater
than or equal to $200,000 or has the combined annual income of you and
your spouse been greater than or equal to $300,000?
____No ____Yes |
| 3. |
Do you anticipate your income will continue at this level?
____No ____Yes |
| 4. |
Is this an account for a trust or business partnership with assets
in excess of $5 million, that was not formed for the purpose of
acquiring unregistered securities?
____No ____Yes |
| 5. |
Is the investor for which you seek registration an entity
wholly-owned by "accredited investors"?
____No ____Yes |
| 6. |
Are you an officer of and investing on behalf of a firm that is a
financial institution, such as a bank, savings and loan association,
insurance company, registered investment company, broker/dealer
organization, employee benefit/retirement plan, business development
company, or a Small Business Investment Company ("SBIC")?
____No ____Yes
|
| |
If you answered yes to any of questions 4, 5 or 6, please
complete the following information:
NAME OF CORPORATION, PARTNERSHIP, TRUST, PENSION PLAN, OR ENTITY:
_______________________________________________________________
EMPLOYER IDENTIFICATION NO.: ________________________________
BUSINESS ACTIVITIES: __________________________________________
STATE AND YEAR OF ORGANIZATION: _____________________________
AUTHORIZED PERSON TO CONTACT: ________________(Title)_________
TELEPHONE NUMBER OF AUTHORIZED PERSON: ____________________
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Attested and Agreed to________
Please Initial |
III. REPRESENTATIONS RE: TAX STATUS, FINANCIAL RESOURCES AND INVESTMENT
SOPHISTICATION
All subsequent references to "I", "Me," or "My" shall refer to the
undersigned.
My tax status is…
| _____ Single |
_____ Head of Household |
| _____ Married Filing Joint Return of Qualified Widow(er) |
_____ Corporation |
| _____ Married Filing Separate Returns |
_____ Other:____________ |
My marginal federal tax bracket is_______%.
- I have sufficient knowledge and experience in financial and business
matters that I am capable of evaluating the merits and risks of the
investments that I may make with the Company and protecting my own
interest in connection with a purchase of securities in a private
placement offering without any outside assistance.
- I will rely upon the advice of my own counsel and accountants and/or
purchaser representative(s) with regard to the tax and economic
considerations involved in making any investment that I elect to make
with the Company.
- I will not purchase any investment offered by the Company with a
view to resell or distribute such investment.
- I understand that the investments I might make with the Company will
be predominantly real estate-related investments. I am specifically
interested in these types of investments and consider myself
knowledgeable regarding the risks involved in real estate-related
investments.
- I have not provided my personal or business financial statements to
the Company, because I consider that information confidential and am not
relying upon the Company for advice regarding whether a particular
investment is suitable for me in light of my present financial
resources. I wish to make that determination myself.
- I understand that investments in securities offered by the Company
contain risks. I consider myself qualified through business and
practical experience to evaluate those risks in determining whether a
particular investment makes sense for me, in light of my present
financial resources, investment experience, and investment objectives.
- I am (or the trust beneficiary for whom I am a fiduciary is) able to
bear the economic risk of an investment in a private placement,
including a complete loss of my investment.
- To the best of my knowledge, I do not have any other investments or
contingent liabilities that could cause the need for sudden cash
requirements in excess of cash that is otherwise readily available to
me.
- Neither I nor my broker or any representative of mine became aware
of or were introduced to the Company by means of any advertisement or
general solicitation.
- The foregoing statements are complete and accurate to the best of my
knowledge and belief, and I agree to notify the Company regarding any
material change in the information set forth above.
Attested and Agreed to_________
Please Initial |
IV. CONFIDENTIALITY
_____ By checking this box, I indicate my desire to obtain the ability
to access
Company information concerning offerings on the Company's website and
agree to the
following terms and conditions.
- I understand that "Confidential Material" shall include any
information disclosed to me in connection with my use of the Company's
website, including, without limitation, the user identification number
and the password to the website issued to me and any information that
relates to or involves any of the investment funds managed by the
Company, including information relating to a fund's performance.
- I shall not have any obligation to preserve the confidentiality of
any Confidential Material which (i) is already in my possession or (ii)
is or becomes generally available to the public other than as a result
of an unauthorized disclosure to me.
- I acknowledge that the Confidential Material is of a proprietary and
confidential nature and that damage to the Company and/or the investment
funds with which it is affiliated could result if the information is
disclosed to any third party. I hereby agree that I will use the
Confidential Material solely for individual investment purposes,
including the purpose of more efficiently evaluating the performance of
any of the investments offered by the Company.
- I agree that, except as required by law, I will keep the
Confidential Material confidential and will not disclose it in any
manner whatsoever, except that I may disclose all or portions of the
Confidential Material to my directors, officers, employees, agents,
affiliates, representatives and advisors (collectively, the
"Representatives") who need to know such information for the purposes of
evaluating an investment in any of the investments offered by the
Company. I shall inform my Representatives of the confidential nature of
the Confidential Material and shall direct my Representatives to treat
such information confidentially and otherwise to comply with the terms
of this Agreement.
- I agree that my rights and interests in gaining access to the
information posted in the Company's website are not transferable or
assignable.
- I understand that the Company does not warrant or insure that its
website will be free from errors, omissions, interruptions, delays,
losses or defects, whether human or mechanical. I further understand
that the Company does not make any warranties, express or implied, of
any kind whatsoever as to its website, including, but not limited to,
any warranties of merchantability or fitness for a particular purpose.
In no event will the Company be liable for any indirect, consequential,
special, exemplary or incidental damages relating to the adequacy,
accuracy or completeness of any information on its website or the use of
any information retrieved from its website.
Attested and Agreed to_________
Please Initial |
VI. INDEMNIFICATION
By signing below, I acknowledge that the foregoing information provided
by me in this Agreement is complete, true and accurate, and that the
undersigned will promptly notify the Company of any changes in such
information. I hereby consent to the disclosure of any such information,
and any other information furnished to the Company, to any governmental
authority, self-regulatory organization or, to the extent required by law,
to any other person. I further acknowledge that the Company is relying on
the information provided by me in order to comply with applicable
securities laws. I hereby agree to indemnify and hold harmless the Company
and its officers, directors, shareholders, employees, affiliates and
agents from and against any and all loss, damage or liability due to or
arising out of any incomplete, untrue or inaccurate information provided
by the undersigned contained in this questionnaire.
Executed this ______day of ____________, 20___
________________________________________
Print Name of Purchaser
________________________________________
Signature of Individual Purchaser, if applicable
By: ____________________________________
Signature of Purchaser's Authorized Agent, if applicable
________________________________________
Title of Authorized Agent, if applicable
______________________________________________________________
PLEASE MAIL THIS FORM TO:
MR. SCOTT POZZI
PRESCIENT VENTURE PARTNERS, LLC
8 NORTH STATE STREET, SUITE 104
LAKE OSWEGO, OREGON 97034
- Remainder of Form To Be Completed by Prescient Venture Partners, LLC personnel -
The originating registered representative of Prescient Venture
Partners, LLC should make the following certification by initialing below
upon the investor's initial completion of this form when such investor
first signs up as an investor with Prescient Venture Partners, LLC.
CERTIFICATION
___________ Certification: Based on my discussions with Purchaser and my
knowledge of Purchaser's financial resources and investment
sophistication, I certify that I believe the representations contained
herein are true and correct, and that I am not aware of any information to
the contrary.
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