JCI WORLD CORPORATION
I understand that (i) the Company will rely upon the information contained herein for purposes of such determination, (ii) the Shares will not be registered under the Act in reliance upon, among other exemptions, the exemptions from registration provided by Section 109.13 thereof, (iii) your request that I complete this Questionnaire does not constitute an offer of Shares to me and (iv) each investor in the proposed transaction may be required to hold his Shares indefinitely. I represent to the Company that (i) the information contained herein is complete and accurate and may be relied upon by such parties and (ii) I will notify such parties immediately of any material change in any of such information occurring prior to the closing of the purchase of any of the Shares.
I understand that if I use the services of an Offeree Representative acceptable to you (an "Offeree Representative") in connection herewith, either by my choice or pursuant to the Company's request, (i) I must acknowledge, in writing and prior to any purchase, such Offeree Representative to be my Offeree Representative in connection with evaluating the merits and risks of my prospective investment in the Shares, (ii) such Offeree Representative must disclose to me, in writing, prior to the acknowledgment referred to above, any material relationship between such Offeree Representative or its affiliates and the Company and its affiliates that exists now or is mutually understood to be contemplated or that has existed, and any compensation received or to be received as a result of such relationship, including any compensation received or to be received in connection with the offering of the Shares, and (iii) I must furnish true and complete copies of the foregoing instruments to the Company promptly upon their execution.
All information is for the sole use of the company and its counsel and will be held in confidence by them, except that the Questionnaire may be furnished to such parties as the Company deems desirable to establish compliance with federal or state securities laws.
Instructions for completing Questionnaire:
Individuals: Questions 1 ? 12 must be completed.
Partnerships: Questions 2,3,4,5,6,7,8,10 and 13 must be completed with respect to the partnership. The general partner(s) of the partnership responsible for making the decision to purchase Shares must complete a Questionnaire answering questions 1,2,3,4,8 and 10. The responses to questions 3 and 8 should include investments made by such person(s) individually and investments made on the behalf of others.
Corporations: Questions 2,3,4,5,6,7,8,10 and 13 must be completed with respect to the corporation. The representative(s) of the corporation responsible for making the decision to purchase Shares must complete a Questionnaire answering questions 1,2,3,4,8 and 10. The responses to questions 3 and 8 should include investments made by such person(s) individually and investments made on the behalf of others.
Trust, Individual Retirement Accounts and Keogh Plans: Questions 2,3,4,5,6,7,8,10 and 13 must be completed with respect to the Trust, Individual Retirement Account or Keogh plan. The representative(s) of the Trust, Individual Retirement Account or Keogh plan responsible for making the decision to purchase Shares must complete a Questionnaire answering questions 1,2,3,4,5,8 and 10. The responses to questions 3 and 8 should include investments made by such person(s) individually and investments made on behalf of others.
ALL INFORMATION WILL BE TREATED CONFIDENTIALLY
(Please print or type)
1. Name: ________________________
Communication should be sent to (check one):
3. I have personally invested during the past five years in excess of:
4. I consider myself to be an
experienced and sophisticated
Investor. [Note ? if answer
is no, you must obtain an Offeree Representative.]
5. I have such knowledge of business,
finance, securities and investment
generally, and such experience (based
on actual participation) in investments,
that I am capable of evaluating the risks
and merits of the investment, and I believe
I can afford the complete loss of my investment
in the Shares. [Note ? if answer is no, you must obtain an Offeree Representative.]
6. I am purchasing the Shares for
investment and have no present
intent to resell the Shares and
I am able to bear the economic
risks of an investment in the
Shares for an indefinite period of time.
7. My financial capacity is such
that the total cost of any
investment I may make will not
exceed 20% of my net worth (or
joint net worth if married) upon the
date of my subscription. [Note if answer
is no, you must obtain an Offeree Representative.]
8. Please indicate below the types of investments you have made in the past five years, giving the estimated amounts and approximate dates of such investment.
9. I will have an attorney, accountant, or other
advisor review these documents for the purpose
of determining the suitability of the investment
with respect to my personal situation and my
decision to participate will be based in part on
such advisor's analysis. IF YES, YOU
MUST COMPLETE THE OFFEREE
REPRESENTATIVE FORM WHICH MAY BE OBTAINED FROM THE COMPANY.
10. I qualify as an "accredited investor" as
defined in the Accredited Investor Certificate
attached hereto as Annex A. IF YES, YOU
MUST COMPLETE AND RETURN A
COPY OF ANNEX A.
11. If I do not qualify as an "accredited investor" as defined in Annex A, my income from all sources before this proposed investment is in excess of the following amounts:
Year Income in Excess of
2006 (actual) $ __________________________________
12. If I do not qualify as an "accredited investor" as defined in Annex A, my personal net worth, or joint net worth with my spouse (excluding homes, home furnishings and automobiles), is: $ _______________________
13. Information regarding entity making the investment.
a. Name of entity: __________________________________________
h. The entity's annual net income from all sources for each of the years set forth below is as follows:
Fiscal Year Income in Excess of
2006 (actual) $ _____________________
i. Net worth: $ _____________________
The information contained herein is complete and accurate to the best of my information and belief, and I will notify you promptly of any change in any of such information. I realize and understand that the Company is relying on the truth of the information herein to determine if it may sell Shares to me for investment.
(Include Title, If Applicable)
JCI World Corporation