Prospective Investor Name (required)

Street Address

City And State

Country

Zip Code/ Country Code

Telephone

Your Email (required)

Place of Birth

Date of Birth

How did you learn about the CCAE regional center

1. Are you an accredited investor, or if you are an immigration lawyer, are your clients accredited investors? This means that at least one of the following applies:

• You have an individual net worth, or you and your spouse and have a combined net worth, in excess of US$1,000,000. (“Net worth” means the excess of total assets at fair market value, (including principal residence, home furnishing, and automobiles) over total liabilities.
OR
• You had individual income, exclusive of any income attributable to my spouse, of more than US$200,000 in the two calendar years preceding the calendar year in which this is submitted, and you reasonably expect to have an individual income in excess of US$200,000 during the current calendar year.
OR
• You and your spouse and had joint income of more than US$300,000 in the two calendar years preceding the calendar year in which this is submitted, and reasonably expect to have joint income in excess of US$300,000 during the current calendar year.
 yes no

2. Do you believe that by reason of your knowledge and experience in business or financial matters that you are capable of evaluating the merits and risks of this investment and that you can protect your own interest in connection with this investment?

I believe that I am capable of evaluating the risk and merits of this project by reason of my business and financial experience:
 yes  no

3. Are you relying upon the advice of a professional adviser in making a final investment decision? If so, please provide that advisor’s name.

(NOTE: A professional advisor in this context is a professional financial advisor who has been employed by the investor to assist in the decision.)
 yes no

Advisors Name

Any additional information you would like to provide to CCAE: