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Offeree Questionnaire


Should an investor desire to register his/her name and be provided with investment details, please complete the following form and return to Palm Coast Florida Group, LLC. (PCFG)

OFFEREE QUESTIONNAIRE FORM

Click here to download a printable pdf application and mail to:

Palm Coast Florida Group, LLC
Attn: Arthur E. Williamson, Jr.
791 Foothill Court
Toms River, NJ 08753
USA

To the General Partners of Palm Coast Florida Group, LLC. ("PCFG")
Palm Coast Florida Regional Center

The following information is furnished to PCFG in order for you to determine whether the undersigned is qualified to invest in the above referenced company pursuant to Section 4(2) and Regulation D of the Securities Act of 1933 as amended (the “Act”) and appropriate provisions of applicable state securities laws. I understand that you will rely upon the following information for purposes of such determination, and that the investment will not be registered under the Act in reliance upon the exemption from registration provided by Section 4(2) and Regulation D of the Act, and appropriate provisions of applicable state securities laws.

ALL INFORMATION CONTAINED IN THIS QUESTIONNAIRE WILL BE TREATED CONFIDENTIALLY.

However, I do agree that you may present this questionnaire to such parties as you deem appropriate if called upon to establish that the proposed offer and sale of the investment is exempt from registration under the Act or meets the requirements of applicable state securities laws.

I hereby provide you with the following representations and information:

ALL RELEVANT FIELDS ARE REQUIRED.

Investor Information
 
Applicant/Investor Name:
Date of Birth:
Gender:
Marital Status:
City of Birth:
Country of Birth:
Country of Citizenship:
Identification Card and or Passport Number:
Country of Issuance:
Passport Issue Date:
Passport Expiration:
Residence Address:
Residence City:
Residence Province / State:
Residence Zip: (If Applicable)
Residence Country:
Home Telephone Number:
Mobile Phone Number:
Fax Number:
Mailing Address: (If other then residence.)
Suite or Apt # :
City:
State:
Zip:
Country:

Employment:

Current Employer:
Current Position:
Annual Salary (US Dollars):
Business Address:
Business City:
Business Province / State:
Business Zip: (If Applicable)
Business Telephone Number:
Business or Professional Education & Degree:
Email Address :

Prior Employment (5 years):
 
Employer 1 Nature of Duties Dates of Employment
Employer 2    
Employer 3    

Information About Your Spouse:
 
Spouse Full Legal Name:
Spouse Maiden Name:
Spouse Date of Birth:
Spouse Place of Birth:
Spouse Country of Citizenship:
Information About Your Children (Under 21 years of Age):  
Number of Children Under Age 21?:
Number of Children turning Age 21 within the next year?:

General Information:
 

Have you or your spouse ever filed for bankruptcy?
If YES Please Explain:  
Have you or your spouse ever been convicted of a crime?
If YES Please Explain:  
How well do you speak English?  
Need Translator Conversational Fluent
Anticipated date of your I-526 petition submission: (Month/Year)

Applicants living in the United States:
 
US Street Address:
Apartment #:
City/Town:
State/Province:
Country
Postal/Zip Code:
Date of Arrival: (Month/Day/Year)

I-94 #: (Arrival and Departure Record #)

I-94 Issuance Date:
I-94 Expiry Date:
Current Non-Immigrant Status:
Expires On: (Month/Day/Year)
Date of Last Entry onto US: (Month/Day/Year)
Place of Last Entry into US:

General Immigration Questions:
 

Are you currently a green card holder?:
If YES when does it expire:
Have you previously held a U.S. Tourist or Business Visa?
(B1 or B2 Visa)
If YES, what type of Visa?
If YES, when was your last Date of Entry?
Have you previously applied for a U.S. Immigration or Non-Immigration Visa or Been denied?
If YES, please provide details why application was denied?
Is there other relevant information regarding your current immigration that we should be aware of for you or any member of your family?

Prior Investments of purchaser:
Amount (Cumulative) US Dollars
 
Capital Stock None Up to $50,000 $50,000 - 250,000 Over $250,000
Bonds None Up to $50,000 $50,000 - 250,000 Over $250,000
Other None Up to $50,000 $50,000 - 250,000 Over $250,000

Financial Information:
(a) My net worth (exclusive of home, home furnishings and personal automobiles) is in excess of:

$100,000 $250,000 $500,000 $1,000,000

(b) My gross income, including tax exempt income for each of the preceding two tax years was equal to or in excess of:

$100,000 $150,000 $200,000  

(c) My anticipated gross income including tax exempt income this year will be equal to or in excess of:

$100,000 $150,000 $200,000  

(d) (1)

I have such knowledge and experience in financial, tax and business matters that I am capable of utilizing the information made available to me in connection with the offering of the investments to evaluate the merits and risks of the investment and to make an informed investment decision. I do not desire to utilize a Purchaser Representative in connection with evaluating such merits and risks. I understand however that PCFG may request that I use a Purchaser Representative.

Initial here:

     (2)

I intend to use the services of the following named person(s) as Purchaser Representative(s) in connection with evaluating the merits and risks of an investment and hereby appoint such person(s) to act as my Purchaser Representative(s) in connection with my proposed purchase of the investment.

Initial here:

List name(s) and contact information of your Purchaser Representative(s), if applicable.

Except as indicated below, any purchases of the investment will be solely for my account, and not for the account of any other person or with a view to any resale or distribution thereof.

Exception:

How did you hear about us?

I represent to you that the information contained herein is complete and accurate and may be relied upon by you for the purpose of complying with all applicable securities laws. The undersigned agrees to notify PCFG promptly of any change in the foregoing information which may occur prior to any investment of PCFG by the undersigned.

INDIVIDUAL INVESTOR:

Name:
Electronic Signature:
Today's Date:

 

Documentation. Please send to the address below:
  • Valid government issued drivers license including photograph.
  • Valid passport (copy of picture page)
  • National Identity card if available
  • Copy of current US Visa (if inside the United States)
  • Copy of I-94 (if inside the United States)

Click here to download a printable pdf application and mail to:

Palm Coast Florida Group, LLC
Attn: Arthur E. Williamson, Jr.
791 Foothill Court
Toms River, NJ 08753
USA


 

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