Accredited Investors
Contact Information
Name
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First Name
Last Name
How Did You Hear of JB Fitzgerald?
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Company / Title
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Preferred Contact Method
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Home Phone
Business Phone
Cell
Email
Home Phone Number
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Area Code
Phone Number
Business Phone Number
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Area Code
Phone Number
Cell Phone Number
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Area Code
Phone Number
Fax Number
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Area Code
Fax Number
Email
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example@example.com
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Address for Correspondence
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Business
Home
State of Voter Registration
Accredited Investors
Status & Suitability
Accreditation Questionnaire
JB Fitzgerald Venture Capital offers investments to Accredited Investors as defined by Regulation D under the Securities Act: The undersigned is accredited by reason of at least one of the following (Check every item that applies):
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1. A natural person with a net worth (excluding my personal residence), individually or joint with a spouse, exceeding $1,000,000;
2. A natural person with individual income in excess of $200,000, or in excess of $300,000 including a spouse's income in each of the two most recent years, and expectation of such income in the current year;
3. A trust with total assets in excess of $5,000,000 not formed for the specific purpose of acquiring membership interest, whose purchase is directed by a sophisticated person as described in Regulation D;
4. A revocable trust created by an investor for his or her benefit who meets one of the first two tests above;
5. An entity in which all of the equity owners are accredited investors.
6. Furthermore, I have investments & cash in excess of $5 million (excluding my personal residence) which may qualify me as a "qualified purchaser".
Prior Investment Experience
Our investments are not suitable for all investors. Any potential investors should have the ability to evaluate risks of an investment and determine suitability and/or consult with a professional advisor: (Check every item that applies)
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1. I have sufficient knowledge and experience in financial and business matters to evaluate the merits and risks of prospective investment.
2. I normally consult with an investment advisor before making an investment decision.
I have experience as an investor in: (Check every item that applies)
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1. Partnerships, LLC's, corporations that invest in real estate, or REIT's
2. Stocked which are listed on a national securities exchange
3. Mutual funds which hold a portfolio primary consisting of stocks
4. Taxable bonds or other debt instruments
5. Tax exempt bonds
6. Other types of investments not mentioned above (Describe below):
Investment Profile / Background
1. Risk Tolerance (Check One):
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Conservative
Moderate
Aggressive
2. Primary source of income:
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Compensation
Investments
3. Over the next five years, I expect my income level to:
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Be the Same or Increase
Decrease
4. I estimate that real estate represents ____% of my investment portfolio
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Excluding my personal residence
5. I am interested in opportunities where I can invest, on average:
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$50,000 or less
$50,000 - $100,000
$100,000 - $250,000
$250,000 - $500,000
$500,000 - $1,000,000
$1,000,000 - $5,000,000
$5,000,000 - $10,000,000
$10,000,000 or more
6. My net worth is:
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$500,000 - $1,000,000
$1,000,000 - $5,000,000
$5,000,000 - $10,000,000
$10,000,000 - $25,000,000
$25,000,000 - $50,000,000
$50,000,000 - $100,000,000
$100,000,000 or more
For the next question, rank investment strategies 1 - 4 in order of priority, 1 = Highest
Growth
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Current Income
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Tax Deferral
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Liquidity
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Request For Materials
I am most interested in the following types of investments
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Equity - Opportunistic, high yield expectations
Equity - Relatively stable, moderate yield expectations
Fixed Income - Debt Products
Please indicate which best describes the person completing this form:
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I myself am an accredited investor interested in investing
I represent a family office that may be interested in investing
Investment advisor/financial planner/accountant/MFO/representative whose clients may wish to invest
I represent an endowment/institution/pension fund
If Advisor/FA/MFO/RR: Do you have a proprietary platform for alternative investments?
Yes
No
If MFO: Number of families/clients?
If Investor Advisor: AUM$?
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