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|  ______________________ x $10,000 per Unit  = Total Purchase Price of USD $__________(Number of Units subscribed for)  ___________________________                ___________________________Signature                                                              Signature (if purchasing jointly) ___________________________                ___________________________Name Typed or Printed                                      Name Typed or Printed ___________________________                ___________________________Entity Name                                                          Entity Name ___________________________                ___________________________Address                                                                Address ___________________________                ___________________________City, State and Zip Code                                    City, State and Zip Code ___________________________                ___________________________Telephone-Business                                          Telephone-Business ___________________________                ___________________________Telephone-Residence                                        Telephone-Residence ___________________________                ___________________________Facsimile-Business                                             Facsimile-Business ___________________________                ___________________________Facsimile-Residence                                           Facsimile-Residence ___________________________                ___________________________Tax ID # or Social Security #                             Tax ID # or Social Security # Name in which Units should be issued:  _______________________________                                                                                                           Dated  ________________________________                                            |
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| INSTRUCTIONS: | PLEASE ANSWER ALL QUESTIONS.  If the appropriate answer is “None” or “Not Applicable”, so state.  Please print or type your answers to all questions.  Attach additional sheets if necessary to complete your answers to any item. |
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| Category A____ |   | The Investor is an individual (not a partnership, corporation, etc.) whose individual net worth, or joint net worth with his or her spouse, presently exceeds $1,000,000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  |
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|           |   |  Explanation.  In calculating net worth you may include equity in personal property and real estate, including your principal residence, cash, short-term investments, stock and securities.  Equity in personal property and real estate should be based on the fair market value of such property less debt secured by such property.                                                                                                                                                                                                                                                                                           |
|           |   |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |
| Category B____ |   | The Investor is an individual (not a partnership, corporation, etc.) who had an individual income in excess of $200,000 in each of the two most recent years, or joint income with his or her spouse in excess of $300,000 in each of those years (in each case including foreign income, tax exempt income and full amount of capital gains and losses but excluding any income of other family members and any unrealized capital appreciation) and has a reasonable expectation of reaching the same income level in the current year.                                                                                                                  |
|           |   |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |
| Category C____ |   | The Investor is a director or executive officer of the Company that is issuing and selling the Units.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      |
|           |   |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |
| Category D____ |   | The Investor is a bank; a savings and loan association; insurance company; registered investment company; registered business development company; licensed small business investment company (“SBIC”); or employee benefit plan within the meaning of Title 1 of ERISA and (a) the investment decision is made by a plan fiduciary which is either a bank, savings and loan association, insurance company or registered investment advisor, or (b) the plan has total assets in excess of $5,000,000 or is a self directed plan with investment decisions made solely by persons that are accredited investors.  (describe entity) |
|           |   |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |
| Category E____ |   | The Investor is a private business development company as defined in section 202(a) (22) of the Investment Advisors Act of 1940.  (describe entity)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              |
|           |   |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |

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| Category F____ |   | The Investor either is a corporation, partnership, Massachusetts or similar business trust, or non-profit organization within the meaning of Section 501(c)(3) of the Internal Revenue Code, in each case not formed for the specific purpose of acquiring the Units and with total assets in excess of $5,000,000.  (describe entity) |
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|           |   |                                                                                                                                                                                                                                                                                                                                             |
| Category G____ |   | The Investor is a trust with total assets in excess of $5,000,000, not formed for the specific purpose of acquiring the Units, where the purchase is directed by a “sophisticated person” as defined in Regulation 506(b)(2)(ii) under the Securities Act.                                                                           |
|           |   |                                                                                                                                                                                                                                                                                                                                             |
| Category H____ |   | The Investor is an entity (other than a trust) all the equity owners of which are “accredited investors” within one or more of the above categories.  If relying upon this Category alone, each equity owner must complete a separate copy of this Questionnaire.  (describe entity)                             |
|           |   |                                                                                                                                                                                                                                                                                                                                             |
| Category I____ |   | The Investor is not within any of the categories above and is therefore not an “accredited investor”.                                                                                                                                                                                                                                |

|   | (a) | For an individual Investor, please describe your current employment, including the company by which you are employed and its principal business: |
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|   | (b) | For an individual Investor, please describe any college or graduate degrees held by you: |
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|   | (d) | For all Investors, please state whether you have you participated in other private placements before: |
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|          Public                                         Private     Companies                                                CompaniesFrequently                      Occasionally                      Never                        |
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|   | (e) | For all Investors, are you familiar with the risk aspects and the non-liquidity of investments such as the securities for which you seek to subscribe? |
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|   | (f) | For all Investors, do you understand that there is no guarantee of financial return on this investment and that you run the risk of losing your entire investment? |
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|   | (g) | For individual Investors, do you expect your current level of income to significantly decrease in the foreseeable future: |
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|   | (h) | For all Investors, do you expect your total assets to significantly decrease in the foreseeable future: |
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|   | (i) | For all Investors, do you have any other investments or contingent liabilities which you reasonably anticipate could cause you to need sudden cash requirements in excess of cash readily available to you: |
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|   | * | If Units are being subscribed for by an entity, the attached Certificate of Signatory must also be completed. |
|--------|---|---------------------------------------------------------------------------------------------------------------|

|   | B. | If Investor is a registered representative with a FINRA member firm, have the following acknowledgment signed by the appropriate party: |
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| ______(Investor’s initials) | The Investor has had access to such information regarding the Company as it deems necessary to make an informed investment decision. |
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| ______(Investor’s initials) | The Investor its investment in this offering does not represent a disproportionate amount of its disposable income, and, that it can bear the total loss of its investment. |
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|   Name of Investor (i.e., name in which Units should be issued)  ___________________________                ___________________________Signature                                                              Signature (if purchasing jointly) ___________________________                ___________________________Name Typed or Printed                                      Name Typed or Printed  Title of Signatory (for entities) ____________________________  Dated _______________________________                                             |
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