Accredited Investor Status:

Please Check Appropriate Box(es):
I warrant to SCIA and their “Presenting Companies” that I am an “accredited investor,” as that term is defined in Regulation D, Rule 501(a) as promulgated under the United States Securities Act of 1933: Specifically:

A natural person whose net worth, or joint net worth with his spouse, exceeds $1,000,000, exclusive of primary residence, and either is able to bear the economic risk of investment in shares;
A natural person who had 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 reasonably expects to reach the same income level in the current year, and is able, either to bear the economic risk of investment in shares;
An organization described in section 501(c)(3) of the Internal Revenue Code of 1986, as amended, (i.e., tax exempt entities), corporation, Massachusetts or similar business trust, or partnership, not formed for the specific purpose of acquiring shares, with the total assets in excess of $5,000,000;
A trust, with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring shares, whose purchase are directed by a sophisticated person as described in the Rule;
A bank as defined in section 3(a)(2) of the Securities Act, or a savings and loan association or other institution as defined under section 3(a)(5)(A) of the Securities Act, whether acting in its individual or fiduciary capacity;  
A broker or dealer registered pursuant to section 15 of the Securities Exchange Act of 1934;  
An Insurance Company as defined in section 2(13) of the Securities Act, and certain other qualified institutional investors.

The suitability standards set forth above represent minimum suitability requirements for members and associates of SCIA, and the satisfaction of such standards by prospective investors does not necessarily mean that any companies presented at SCIA conferences are a suitable investment for them. 

Any investment in a company involves a high degree of risk and only those persons who can afford to sustain a total loss of their investment should consider an investment in any of the companies presented at the SCIA / NCS conferences I hereby represent that I am a sophisticated investor and able to evaluate the merits and risks of any investment.  

I HEREBY deem that the foregoing is true and accurate, and I covenant and agree to INDEMNIFY and hold SCIA, its members, affiliate members and/or any of their presenting companies free and harmless in connection with proposed investments.

Electronic Signature:  By checking this box, I agree to the foregoing.    
Name: Date:  
Company Name: Title:  
Address: City:
State: Zip: email:    
Phone: Cell: Dedicated Fax:  
Referred by:

Broker/Dealer                  Investment Banking       Capital Formation              
Fund Manager                   RIA                             Research/Analyst
Market Making                  Secondary Financing     Debt Placement              
Investor Relations              Media                           Securities Attorney
Mergers/Acquisitions          Industry Consultant     Accredited Investor
other