I. Type of Opportunities you are interested in:

Name:

Title:

Business or Organization:

Cellular Phone:

Home Phone:

Work Phone:

Facsimile:

Mailing Address:

City:

State:

Country:

Zip:

E-Mail:

II. Read the accredited investor certification and acknowledge below.
I hereby acknowledge and certify that I am an Accredited Investor as defined by the United States Securities and Exchange Commission's Regulation D, Rule 501, because (check all that apply):

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 of those years, and I (we) have a reasonable expectation of reaching the same income level in the current year;

I am a principal or 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 a 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 1958; or

I am a principal or a 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 total assets in excess of $5 million.

Ill. Read the legal disclaimer and acknowledge below.

1. Investing in private placements involves a degree of risk, and investors should not invest any funds unless they can afford to lose their investment.
2. In making an investment decision, investors must rely on their own examination of the securities issuer and the terms of the securities. It is solely the investor's responsibility to determine and consider thoroughly the validity, merits, and risks of each offer made by the small business before investing in it.
3. Securities listed have not been recommended by any federal or state securities commission, regulatory authority or government entity. Furthermore, none of these authorities have confirmed the accuracy, or determined the adequacy, of the securities issuer's information listed. Any representation to the contrary by anyone is a criminal offense.
4. All investors are encouraged to seek legal counsel and other professional advice prior to entering any investment transactions.
5. The information you provide on this Application will be kept strictly confidential; however you hereby agree that we may provide this Application to such parties as necessary for verification in order to assure that any sale of securities resulting from a listing will not result in violation of securities law.

I hereby acknowledge that I have read, understand, and agree to the above disclaimer.

Today's Date: