Please enter your tax identification and certification information in the fields below. The W-9 Form is to be completed by US citizens only (including resident aliens).
Why do I need to provide my taxpayer identification?
The IRS requires that we obtain your W-9 certification at the time of your investment into our company. This information is transmitted via SSL directly to our transfer agent Colonial Stock Transfer and is stored on their secure servers.
If you do not have a US Taxpayer Identification Number and you are an individual you must complete IRS form W-8BEN and email to email@example.com with your name and the stock being purchased in the subject line. Or you can mail the completed form to:
Please Select One of the Following
If this Taxpayer Identification Number is for one of these Federal Tax Classifications, do not complete this form. You must complete and mail this IRS form W-9 with your completed subscription agreement to:
Under penalties of perjury, I certify that
Please Select a Classification
Because you are subject to backup withholding tax will be withheld on all proceeds!
How do I know if I am subject to backup withholding?
U.S. citizens and resident aliens will be exempt from backup withholding if:
1. You properly report your name and Social Security number to the payer using Form W-9, and that information matches the IRS records, and
2. You have not been notified by the IRS that you are subject to mandatory backup withholding.
Please enter your annual household income or net worth and investment amount into the fields below.
Minimum purchase amount N/A
Maximum purchase amount $1,000,000.00
*Please note that the Number of Shares will be automatically calculated
after you enter your Annual Household Income or Net Worth, your Investment Amount, and check the acknowledgement checkbox.
Please review the following subscription agreement and click the checkbox to agree to its terms. By doing so you are electronically signing the subscription agreement.
Please click to view the subscription agreement in PDF format. You may download Adobe Reader for free by visiting https://get.adobe.com/reader/.
Please select the method of payment to fund your investment.
By clicking 'Next' on this step and then 'Submit' on the following step, this constitutes my electronic signature, wherein I hereby authorize the Issuer of this Offering, or its agents, to debit my bank account for the dollar amount subscribed to in this Offering.
This is a single transaction, and does not provide authorization for additional debits.
Please review your information for accuracy and confirm your investment.
Please enter your accredited investor confirmation number before proceeding.
Please include the dashes (Format XXXX-XXXX-XXXX)
Please enter the offering password.