| Name:
|
_____________________________________________
|
| E-Mail:
|
_____________________________________________
|
| Company:
|
_____________________________________________
|
| Street
Address: |
_____________________________________________
|
| City,
State, Zip: |
_____________________________________________
|
| Phone:
|
_____________________________________________
|
| Preferences:
|
|
| Industry
(ies) |
_____________________________________________
|
| Geographical
Preference |
_____________________________________________ |
| Range
of Preferred Investment Size |
_____________________________________________ |
| Within
the last 5 years, in how many private ventures have you invested?
|
_____________________________________________ |
| Other
Comments: |
_____________________________________________
_____________________________________________
|
Yes___No__ I am interested in membership in the Tri-State
Private Investors Network.
I qualify as an "accredited investor" as defined in Rule 501(a)
of Regulation D.
|
| Signature: |
_____________________________________________ |
|
|
