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Private Accredited Investors

The Tri-State Private Investor Network has been formed.

If you are a private, accredited investor and are interested in the Tri-State Private Investors Network, PLEASE PRINT AND SIGN THE FORM BELOW AND FAX IT TO 212-995-0788. This information will remain confidential.


Name: _____________________________________________
E-Mail: _____________________________________________
Company: _____________________________________________
Street Address: _____________________________________________
City, State, Zip: _____________________________________________ 
Phone: _____________________________________________
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: _____________________________________________
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