Avatar Equities – Investment Inquiries

We always welcome new investors seeking alternative investment options. Please fill out the questionnaire below, and we will reach out to you shortly to discuss with you further. Thank you in advance for your interest.

Confidential Investor Questionnaire

( ALL INFORMATION IS AND SHALL REMAIN CONFIDENTIAL )

1. FOR INDIVIDUAL INVESTORS:

First *First Name of Applicant
Last *Last Name of Applicant
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone *Phone of Applicant
Email *Email of Applicant
Date of Birth *Applicant's Date of Birth
U.S. Citizen *
YesNo
College Name of establishment where applicant attended college
Year
Degree Type of Degree such as Bachelor of Science and in what field
Graduate School Name of establishment where applicant attended Graduate School
Year
How did you hear about us?
Business/Employer Name *
Nature of Business or Employment *
Occupations or Duties *
Please set forth other prior occupations or duties during the past five years:
Year of Anticipated Retirement

2. FOR INVESTORS THAT ARE CORPORATIONS, PARTNERSHIPS, TRUST OR OTHER ENTITIES:

Name Name of Corporation, Partnership, Business, or Trust
Office Phone
Address of Principle Office
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
State and Date of Incorporation or Organization State of LLC or INC and Date it became effective
Taxpayer Identification Number
Nature of Business
Name and Title Name and Title of Authorized Individual to execute this questionnaire
Name of record and beneficial owners of entity (10% ownership or more):
Please list name and percentage of ownership below. One name per line.

3. FOR ALL INVESTORS

a) Relationship to the Company or managers of the Company
b) The undersigned is an officer or director of a publicly-held company?
YesNo
If yes, please specify:
c) I ____ personally invested in investments sold by means of private placements within the past five years.
havehave not
d) Please list all investments made during the past five years. (Include dates, nature and amounts of investment)
e) Do you consider yourself to have such knowledge and experience in financial and business matters to enable yourself to evaluate the merits and risks of investment in the Company?
YesNo
If yes, please set forth below the basis for your answer (e.g. investment or business experience, profession, past review of other investment offerings, etc.)
f) Listed below are the categories of accredited investors, as defined by Regulation D, promulgated under the Securities Act of 1933, as amended.
Please check the appropriate space provided below if the Investor falls within one or more of these categories.
(1) Any natural person whose individual net worth or joint net worth with that person's spouse, at the time of his purchase, exceeds $1,000,000. Net worth includes homes, furnishings and automobiles.(2) Any natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with that person's spouse in excess of $300,000 in each of those years and has a reasonable expectation of reaching the same income level in the current year.(3) A bank, insurance company, registered investment company, employee benefit plan if the investment decision is made by a bank, insurance company or registered investment adviser, or an employee benefit plan with more than $5 million of assets.(4) Any private business development company as defined in Section 202(a) (22) of the Investment Advisers Act of 1940.(5) Any organization described in Section 501(c)(3) of the Internal Revenue Code, corporation, Massachusetts or similar business trust, or partnership, not formed for the specific purpose or acquiring the securities offered, with total assets in excess of $5,000,000.(6) Any director, executive officer or general partner of the issuer of the securities being offered or sold, or any director, executive officer or general partner of a general partner of that issuer.(7) Any trust with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the securities offered, whose purchase is directed by a sophisticated person as described in Rule 506(b)(2)(ii).(8) Any entity in which all of the equity owners are accredited investors.(9) The Investor does not qualify in any accredited category as indicated above.
Please indicate whether you intend to have an attorney, accountant, investment advisor or other consultant act as its Purchaser Representative in connection with this investment:
YesNo
If yes, please list below the name, business address and telephone number of the person who is your purchaser representative.
Representative Name
Firm
Phone
Address of Representative
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
If the undersigned utilizes a Purchaser Representative, the Purchaser Representative will be required to complete a questionnaire to be supplied by the Company.

4. GROSS INCOME

If the undersigned is an individual. was your personal income from all sources for the previous calendar year more than (check the HIGHEST number applicable for each year.)
2011
$150,000$200,000$250,000
2010
$150,000$200,000$250,000
2009
$150,000$200,000$250,000

5. NET WORTH

My estimated liquid assets equal:
My estimated non-liquid assets equal:
Entities
If the undersigned is an entity which checked item (8) under Paragraph 3(f) above in reliance upon the accredited investor categories set forth in items 1 and 2 of Paragraph 3(f), please state the name, address, total personal income from all sources for the previous calendar year, and the net worth (exclusive of home, furnishings, and personal automobiles) for each equity owner of said entity.
Investor Acknowledgement The Investor hereby certifies that the information contained herein is complete and accurate and the Investor will notify the Company promptly of any change of information. Specifically, the Investor hereby certifies that the information contained above concerning the residency of the Investor is true and correct. The Investor realizes and understands that, but for the truth of the information contained herein, the Investor would not receive consideration by the Company pertaining to this investment. If the Questionnaire is completed on behalf of a corporation, partnership, trust, or estate, I, the person executing on behalf of the Investor, represent that I have the authority to execute and deliver the Questionnaire on behalf of such corporation, partnership, trust, or estate.
Date

Signature for Individual Investor

Signature
Name
Signature of Joint Investor
Name of Joint Investor

SIGNATURE FOR PARTNERSHIPS, TRUST, CORPORATION OR OTHER ENTITY

Name of Investor
By:
Signature
Name
Title
Digital Signature By checking this box, you agree and understand that using an "electronic signature" is legal and binding. By filling in the field labeled "Signature," you are agreeing that all the information given is to the best of your abilities true.
*
I Agree

Verification

Please enter any two digits with no spaces (Example: 12) *
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Confidential Investor Questionnaire

1. FOR INDIVIDUAL INVESTORS:

2. FOR INVESTORS THAT ARE CORPORATIONS, PARTNERSHIPS, TRUST OR OTHER ENTITIES:

3. FOR ALL INVESTORS

4. GROSS INCOME

5. NET WORTH

Signature for Individual Investor

SIGNATURE FOR PARTNERSHIPS, TRUST, CORPORATION OR OTHER ENTITY

Verification

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