Membership is restricted to "Accredited Investors" as defined:

Indicate whether you are joining as an individual or a representative.  A company cannot be a member — only the representative.

ATTACH A BRIEF BUSINESS BIOGRAPHY, NOT MORE THAN ONE PAGE, AND A HISTORY OF YOUR VENTURE CAPITAL INVESTMENTS. THE BIOGRAPHY WILL BE CIRCULATED TO THE MEMBERSHIP BUT THE INVESTMENT HISTORY WILL BE KEPT CONFIDENTIAL.

I DECLARE ALL STATEMENTS TO BE TRUE AND CORRECT AS OF THIS DATE:

Date_______________________

Name                                                                                                                                      

Signature                                                                                                                                 

Company (if representative)                                                                                                     

Address                                                                                                                                  

Phone                                                                           Fax                                                     

Email                                                                            Web