Investor Class Assessment

Please complete the following form and send it to us.

Given name(s)
Surname (Family name(s))
Date of birth (day/month/year)
Telephone Number
Fax Number
E-mail address

Country currently residing in
How did you hear of us?

What is your current net worth in Canadian or US currency?
Name of company (list if more than one business)
Your position with the company
Dates you held this position. From	to
Type of business activity or product
Your role in the daily activities
Amount of equity in the company that belonged to you (percentage)

Please list the company's:
number of full time employees
total annual sales
annual net income
net assets at year end

Are you willing and able to make an investment of either $400,000 or $120,000/year for a period of 5 years to participate in this program?

Confirm e-mail address

Please review your details prior to submission.