Officer & Director Questionnaire
Please complete this questionnaire for full and adequate disclosure. If a specific question
is not applicable, please indicate. If you require additional space for answering a
question, attach extra sheets.
1. Please provide the following personal information:
Name: _______________________________________
Address: _____________________________________
__________________________________________
__________________________________________
Date of Birth: ____ / ____ / ____
2. Do you have a family member or relative who is also a director or officer of this
company? ___ No ___ Yes
If Yes, please disclose this relationship:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
3. Describe your present occupation and position:
Job Title / Retired : ____________________________________________________
Employer Name: ______________________________________________________
Principal Business: ____________________________________________________
Number of Years in this Position: ________
4. List prior occupations and positions (during last ten years)
Start Date Stop Date
Title
Employer
___/___ ___ /___ ______________________
________________________
___/___ ___ /___ ______________________
________________________
___/___ ___ /___ ______________________
________________________
___/___ ___ /___ ______________________
________________________
___/___ ___ /___ ______________________
________________________
___/___ ___ /___ ______________________
________________________
___/___ ___ /___ ______________________
________________________
5. Describe your proposed position and responsibilities within the company:
Title: _____________________________________
Primary Responsibility: _________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
6. Please indicate any other company where you are currently serving as an Officer or
Director:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
7. List any and all forms of compensation you have or will receive as an Officer or
Director with our company:
Type of compensation (fees, salary, bonus, property, etc.) _________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Frequency of compensation: ________________________________________
_______________________________________________________________
_______________________________________________________________
Benefits: (use of company property, club memberships, insurance, etc.)
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
8. Will or have you or any family member or relative used company property and assets
for personal use? ____ Yes
____ No
If Yes, please describe use: __________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
If Yes, did you or your family member or relative reimburse the company?
____ Yes ____ No
9. Will the company provide you or any family member or relative with special services,
such as tax return preparation, personal financial planning, legal services, or other
services for your own personal use? ____ Yes ____ No
If Yes, please describe: ______________________________________________
_________________________________________________________________
_________________________________________________________________
10. Will or have you or any family member or relative received benefits from suppliers,
customers, or other parties which does business with the company? ___Yes ___No
If Yes, please describe benefits (free memberships, special discounts, reduced rates,
gifts, and other forms of compensation) and source:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
11. Are you actively working as a “promoter” of the company; i.e. you are directly or
indirectly behind creating and organizing the company ____ Yes ____ No
If Yes, did you receive any form of compensation as a promoter? ___ Yes ___ No
What was the form of this compensation? ________________________________
__________________________________________________________________
__________________________________________________________________
12. Please fully disclose your current equity ownership in the company. This would
include the total number of shares you own, date acquired, the amount you paid, if the
ownership allows voting rights, and if the ownership allows you to sell the shares.
Also disclose if family members or relatives have an equity interest in the company.
# of Shares
Date
Amount
Owned
Acq
Paid
Voting Power
Able to Sell
Your Ownership:
_______
________
___________ Yes No
Yes No
Spouse:
_______
________
___________ Yes No
Yes No
Family Member(s):
_______
________
___________ Yes No
Yes No
Relatives:
_______
________
___________ Yes No
Yes No
Trust:
_______
________
___________ Yes No
Yes No
Owned by Company, Partnership or other entity where you are an Officer/Director:
_______
________
___________ Yes No
Yes No
13. Please fully disclose any options, rights, or other bonus type arrangements you own
with the company:
Date
Amount
Exercise
Type of Arrangement
Acquired
Duration
Paid
Price
_________________
________
________
________
_________
_________________
________
________
________
_________
14. Do you now or do you plan on having any type of arrangement or agreement with any
person or entity that has or will have an equity ownership interest in the company
with respect to first offer, pledge, or other transfer of stock of the company?
____ Yes ____ No
If Yes, please describe this arrangement or agreement, disclosing the parties involved
and number of shares affected: ________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
15. Are you aware of any arrangement or possible change in the control of the company,
including a pledge of securities? ____ Yes
____ No
If yes, please describe the persons involved and the nature of the change:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
16. In the last five years, please indicate if you have filed or anyone has filed against you
a petition under the Bankruptcy Act or any insolvency laws of any state or country.
____ Yes ____ No
17. In the last ten years, please indicate if you have been convicted in any criminal
proceeding, exclusive of traffic violations and misdemeanors.
____ Yes ____ No
If Yes, indicate the nature of the conviction, name of court, date of conviction, and
the penalty or disposition of the case:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
18. In the last ten years, indicate if you were subject of a court order, judgement, or
decree of any court which enjoined or otherwise limited your capacity for acting as an
investment advisor, underwriter, broker, dealer, or affiliated person, director, officer,
or employee of any investment company, bank, insurance company, or any activity
connected to the purchase or sale of securities under federal and state securities laws.
_____ Yes ____ No
If Yes, indicate the nature of the restriction, date imposed, and the penalty or
disposition of the restriction:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
19. Complete the following information if you or any business associate of yours is or
has been indebted to the Company at anytime since formation of the Company:
Name of Borrower: ______________________________________
Maximum Amount of Debt: _______________________________
Amount Currently Outstanding: ____________________________
Annual Interest Rate: _________
Terms, Conditions, and Description of Loan: ________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
20. Indicate if you or any business associate is party to a pending lawsuit or legal
proceeding involving the Company or the assets of the Company?
_____ Yes _____ No
If Yes, describe the lawsuit or legal proceeding, the name of the court, the amount
claimed, the parties involved, and date(s) of such proceedings:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
21. To the best of your knowledge, are you aware of any material legal proceeding not
before mentioned in question #20 which could have a substantial effect on the
financial condition of the Company?
_____ Yes _____ No
If Yes, describe the pending legal proceeding, the name of the court, the amount
claimed, the parties involved, and date(s) of such proceedings:
___________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
22. Describe any interest you have or any business associate has in any legal proceeding
which could be adverse to the Company?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
23. To the best of your knowledge, are you aware of any agreement, trust, or other
arrangement which holds more than 5% of the Company? d
____ Yes ____ No
If Yes, indicate the amount held and the duration of the agreement:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
24. To the best of your knowledge, are you aware of any director, officer, or partner who
is insured or indemnified against liability in his or her capacity as a director, officer,
or partner?
_____ Yes _____ No
If Yes, identify the name(s), position(s), and extent of indemnification if known?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
25. Do you have any relationship with an investment banker, broker, underwriter or other
securities dealer which is more than the usual maintenance of an open account?
_____ Yes _____ No
If Yes, describe this relationship(s): ______________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
26. Do you have any material interest, association, affiliation, or relationship with the
Underwriter or Legal Council for the Company?
____ Yes ____ No
If Yes, describe the relationship: __________________________________________
_____________________________________________________________________
_____________________________________________________________________
27. Are you aware of any arrangement or agreement which is designed to: a) limit or
restrict the sale of interest in the Company; b) stabilize the marketplace for the stock
of the Company being registered; c) hold underwriters and/or dealers responsible for
their participation; or d) change control of the Company?
_____ Yes _____ No
If Yes, describe the details of the arrangements:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
28. Identify the sale of unregistered securities by you or any person, firm, company
where you have a controlling interest or you serve as director, officer, partner for the
last three years:
Name of Issuer: ___________________________________
Date of Sale: _____________________________________
Type of Security: _________________________________
Name of Purchaser: _______________________________
Purchase Price: ___________________________________
Total Amount of Transaction: _______________________
Relationship of Purchaser: __________________________
Residence of Purchaser: ____________________________
Occupation of Purchaser: ___________________________
NOTE: Attach documentation regarding the sale(s)
29. Have you ever been indemnified by the Company as a result of serving as an officer,
director, partner, agent, or employee of the Company?
_____ Yes _____ No
If Yes, describe the indemnification: ______________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
30. Have you ever been disqualified, censored, or reprimanded by a professional
organization or association while practicing as a professional (such as lawyer, doctor,
realtor, CPA, etc.)?
____ Yes ____ No
If Yes, describe the actions taken and the current disposition:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
31. What is the present state of your physical health?
____________________________________________________________________
____________________________________________________________________
32. If you have consented to accept a position or role within the Company (such as
director, advisor, etc.), please describe your role:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
The information provided in this questionnaire is supplied for the purpose of
disclosing certain information to potential investors. If there is any other
information not previously covered in this questionnaire that you believe should be
disclosed, then set forth all relevant information as an attached sheet. In the event
that other developments or circumstances make the information disclosed in this
questionnaire misleading, false, incomplete or otherwise inaccurate, notify the
Company or its legal council immediately.
I AGREE TO THE INFORMATION SET FORTH IN THIS QUESTIONNAIRE AND I
AGREE TO FURNISH THE COMPANY OR ITS LEGAL COUNCIL WITH ANY
DEVELOPMENTS THAT MAKE THE QUESTIONNAIRE FALSE, INCOMPLETE,
OR MISLEADING.
______________________________________
(Signature)
______________________________________
(Print Name)
_____________________
(Date)