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Form #1561

PURCHASER REPRESENTATIVE QUESTIONNAIRE

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PURCHASER REPRESENTATIVE QUESTIONNAIRE


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PURCHASER REPRESENTATIVE QUESTIONNAIRE

 

 

______________________ Name of Company

______________________ Address of Company

______________________

 

Dear Sir or Madam:

 

The information contained herein is being furnished to you in order to enable you to determine whether the undersigned may act as purchaser representative pursuant to Section 4(2) of the Securities Act of 1933, as amended, and Regulation D promulgated thereunder in connection with the proposed offer and sale of

securities of _____________________________________________ (the ''Company'').

 

[Please attach additional sheets if required.]

 

1. Name _______________________________________________

 

Age: _________________

1

Home Address: _________________________________________

 

Home Telephone Number: ________________________________

 

2. My present occupation or position is as follows:

 

Firm Name: ________________________________________________

 

Nature of Business: .__________________________________________

 

Position: ___________________________________________________

 

Nature of Duties: ____________________________________________

 

Business Address: ___________________________________________

 

Business Telephone Number: .__________________________________

1

3. Any other prior occupations or positions I have held during the past five years:

__________________________________________________________________

__________________________________________________________________

 

4. I have had prior experience in advising clients with respect to the following types of investments:

a) Real Estate _                                         Yes ____ No ____

b) Oil and Gas _                                         Yes ____ No ____

c) Cattle _                                                  Yes ____ No ____

d) Other Tax Shelters. _                            Yes ____ No ____

 

5. The professional licenses or registrations (including bar admissions, accounting certificates, real estate brokerage licenses, broker dealer or investment advisory registration) held by me are:

 

                                                                                                  Check if License

  License or                                                                               or Registration

  Registration                              Year Received                       is Still Effective

____________________           ____________                       ______________

 

6. (a) Neither I, nor any of my affiliates*, now have or have had at any time since [two

 

years previously], any material** relationship the Company or any of its affiliates and no such relationship is mutually understood to be contemplated, except:______________________________________________________________

____________________________________________________________________

 

* The term ''affiliate'' of a person means a person that directly or indirectly, through one or more intermediaries, controls or is controlled by or is under common control with such person.

** The term "material,'' when used to modify "relationship,'' means any relationship that a reasonable investor might consider important in the making of the decision to acknowledge a person as his purchaser representative.

 

(b) The amounts of compensation received or to be received as a result of the material relationship(s) described in Item 6(a) (including any compensation received or to be

received in connection with this transaction) are:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

 

 

 

______________________________                                             ______________

Signature of Purchaser Representative                                           Date

 

 

 

Contributed by
AIG Legal
 
Total Forms Contributed 75
 

See All AIG Legal's Forms
 

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Terms Of Use

Submissions to this site, including any legal or business forms, posts, responses to questions or other communications by contributors are not intended as and should not be construed as legal advice. You are strongly encouraged to consult competent legal council before engaging in any action based upon content contained on this site.

These downloadable forms are only for personal use. Retransmission, redistribution, or any other commercial use is prohibited. This includes reposting forms from this site to another site offering free legal or other document forms for download.

Please note that the donator may have included different usage terms regarding this form, and you agree to abide by these terms. It is highly recommended that you have a licensed attorney review any legal documents for which you are searching in order to make sure that your needs are being properly and completely satisfied.

Your use of this site constitutes your acceptance of our terms of use and your agreement to hold this site, its officers, employees and any contributors to this site harmless for any damage you might incur from your use of any submissions contained on this site. If you do not agree to the above terms, please do not proceed.

These forms are provided to assist business owners and others in understanding important points to consider in different transactions. They are offered with the understanding that no legal advice, accounting, or other professional service is being offered by these documents or on this website. Laws vary in the different states. Agreements acceptable in one state may not be enforced the same way under the laws of another state. Also, agreements should relate specifically to the particular facts of each situation. Therefore, it is important to consult legal counsel whenever utilizing these forms. The Forms are not a substitute for legal advice YourFreeLegalForms.com is not engaged in recommending or referring members on the site or making claims about the competence, character or qualifications of its participating members.
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