3LB Accredited Investor Offeree Questionnaire and Certifications
Street Address Line 2
State / Province
Postal / Zip Code
Occupation (Including Title)
Education (Highest Level Completed)
$5M or more
$1M to $5M
Less than $1M
Gross Income (Average for last 2 years)
$300k or more
Less than $200k
Is this income combined with that of your spouse?
Do you expect a similar level of income this year?
I utilize the services of the following attorney, accountant or other advisor to assist me in analyzing investment opportunities (include name/occupation/email):
Name of vesting entity:
Type of entity:
I am an “accredited investor” as defined in Rule501(a) of Securities and Exchange Commission Regulation D
I have adequate means of providing my currentneeds, and possible personal contingencies, and have no need for liquidity inan investment in the Company
I, together with my advisors, have specificknowledge and experience in related financial and business matters so as to becapable of evaluating the relative economic and operational merits and risks ofan investment in the stock.
I hereby certify that I have answered theforegoing questions to the best of my knowledge and that my answers hereto arecomplete and accurate.
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