The information you provide below will be kept strictly confidential and is only for the purpose of determining that you meet the definition of Sophisticated or Accredited Investor as required by State and Federal law.

This is not an offer of securities. The actual investment offering will be made only through a Private Placement Memorandum.

After you complete this questionnaire, we will contact you. If you would prefer to download a PDF version of this form, which you can e-mail or FAX, click here.

Thank you for your interest in Synergetic Investment Group, LLC.                  *Required Field  


At least one of the following questions must be answered in the affirmative to qualify. Please check all that apply:

I have had an individual income in excess of $200,000 in each of the two most recent years, or joint income with my spouse in excess of $300,000 in each of the two most recent years, and have reasonable expectation of reaching the same income level in the current year.

I have an individual net worth or joint net worth with my spouse in excess of $1,000,000, excluding the equity in my/our primary residence.

I, either alone or with a purchaser representative have sufficient knowledge and experience in financial and business matters to make me capable of evaluating the merits and risks of a prospective investment.

I represent a trust with assets in excess of $5 million, not formed to acquire the securities offered, whose purchases a sophisticated person makes.

I represent a bank, insurance company, registered investment company, business development company, or small business investment company.

I represent an employee benefit plan, within the meaning of the Employee Retirement Income Security Act, if a bank, insurance company, or registered investment adviser makes the investment decisions, or if the plan has total assets in excess of $5 million.

I am a director, executive officer, or general partner of the company selling the securities.

I represent a charitable organization, corporation, or partnership with assets exceeding $5 million.

By clicking the Submit button, I am verifying that I have read the required disclaimer and the foregoing statements are true and accurate to the best of my knowledge. I will promptly notify Synergetic Investment Group, LLC of any changes in the foregoing answers.

Be sure to set up an appointment on the next page.