EB5 KYC

EB5 Application/Questionnaire Form
ALL INFORMATION CONTAINED IN THIS QUESTIONNAIRE WILL BE TREATED CONFIDENTIALLY.

However, I do agree that you may present this questionnaire to such parties as you deem appropriate if called upon to establish that the proposed offer and sale of the investment is exempt from registration under the Act or meets the requirements of applicable state securities laws.

All Fields Are Required
I hereby provide you with the following representations and information:
Full Name*
Male*

YesNo
Female*

YesNo
Other Name or Aliases*
Full Name ins Native Alphabet*
Social Security Number*
Passport Number*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Country of Citizenship*
Marital Status*

YesNo
Spouse's Name*
Date of Marriage*

MonthDayYear
Date
Spouse's Place of Birth*
Spouse's Country of Citizenship*
Spouse's Date of Birth*

MonthDayYear
Date
What is your current Occupation?*
Level of English "Click on appropriate Box"*

Need TranslatorConversationalFluent
Children - if "None" so State*
Q1. Have you or your spouse ever visited the United States? If yes, please briefly explain the circumstances, including location(s) and date(s).*
Q2. Have you or your spouse ever been denied entry to the United States? If yes, please briefly explain the circumstances, including the location(s) and date(s).*
Q3. Have you ever applied for Permanent Resident Status? If, yes, please give date and place of filing and final disposition of your case.
Q4. Have you ever been deported from the United States? if yes, please give date and place and a brief explanation.*
Q5. Have you or your spouse ever been arrested and/or convicted of a crime? If yes, briefly explain the circumstances, including location(s) and date(s).*
Q6. Have you or your spouse ever filed for bankruptcy? If yes, please briefly explain the circumstances.*
Q7. Have you ever invested in a business in the United States? If yes, please briefly explain the circumstances.*
Q8. Summarize your past work experience(s) job title, dates started/ended, and Company Names, including your present occupation).*
Q9. Will you be able to clearly document that the cash required to make your investment comes from a lawful source such as profit or earnings from a business, the profits or proceeds from the sale of real estate, or the profits or earnings from stock or other investments, inheritance, gifts or loans?*
Does your family meet one or more of the following?
U.S. $200,000 Annual Income This Year and Past two (2) years?*

YesNo
Net Worth in Excess of U.S. $1,000,000*

YesNo
Net Worth in Excess of U.S. $500,000*

YesNo
Referred by:*

First NameLast Name
By my signature below I do agree that you may present this questionnaire to such parties as you deem appropriate if called upon to establish that the proposed offer and sale of the investment is exempt from registration under the Act or meets the requirements of applicable state securities laws.

I attest that the information presented in this Application is true to the best of my knowledge.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature

Clear
Please verify that you are human*
Should be Empty:

EB5 Application/Questionnaire Form

Does your family meet one or more of the following?