Contact Information
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Relationship and Source of Inquiry
How did you learn of the Company? (required)—Please choose an option— Existing relationship with a Company officer or director Referral from an existing investor or advisor Introduced by a named third party Conference, industry event, or scientific meeting Company website Social media Other
If referred or introduced, please name the person or organization
Describe any prior relationship you have with the Company or its principals, including approximate date it began
Investor Classification
You are inquiring as: (required)
Accredited investor certification. Select every category below that applies to you. These categories are defined in Rule 501(a) of Regulation D under the Securities Act of 1933.
Individual income exceeding $200,000 in each of the two most recent years, with a reasonable expectation of the same in the current year Joint income with a spouse or spousal equivalent exceeding $300,000 in each of the two most recent years, with a reasonable expectation of the same in the current year Individual or joint net worth exceeding $1,000,000, excluding the value of my primary residence I hold a Series 7, Series 65, or Series 82 license in good standing I am a director, executive officer, or general partner of the issuer I am a knowledgeable employee of the private fund making the investment Entity with total assets exceeding $5,000,000 that was not formed for the specific purpose of this investment Entity in which all equity owners are accredited investors Bank, insurance company, registered investment company, business development company, or small business investment company Family office with at least $5,000,000 in assets under management, not formed for the specific purpose of this investment, whose investment is directed by a knowledgeable person None of the above apply to me
If you selected "None of the above," we are not able to provide confidential investor materials at this time. You are welcome to contact us regarding commercial, distribution, or scientific collaboration instead.
Indicative interest range (optional — non-binding)—Please choose an option— Under $100,000 $100,000 – $500,000 $500,000 – $2,000,000 Over $2,000,000 Prefer not to say
Area of interest—Please choose an option— Equity investment Strategic or corporate investment Licensing or partnership Distribution Other
Additional information
Acknowledgments
All items below are required.
I have read and understand the Company's Investor Disclaimer , and I agree to its terms.
I understand that this form is not an offer to sell or a solicitation of an offer to buy any security, that no securities are being offered to me by means of this form or the Company's website, and that any offer would be made only through definitive offering documents.
I understand that the Company and its representatives are not acting as my broker, dealer, investment adviser, or fiduciary, and that no communication from the Company constitutes investment, legal, tax, or accounting advice.
I understand that any investment in the Company would be speculative and illiquid, would involve a high degree of risk including the risk of losing my entire investment, and that the Company's products are in development and have not been cleared or approved by the FDA.
I understand that before receiving confidential materials I will be required to execute a non-disclosure agreement and to provide third-party verification of my accredited investor status, which may include documentation from a licensed attorney, CPA, registered investment adviser, or registered broker-dealer.
I certify that the information I have provided is true, accurate, and complete, and I agree to notify the Company promptly if it ceases to be accurate.
I consent to the Company's collection and use of this information in accordance with its Privacy Policy .
I consent to being contacted by phone, email, and text message at the details provided regarding my inquiry. Message and data rates may apply. I may withdraw this consent at any time.
Electronic Signature
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By typing your name above you are signing this request electronically and agree that your electronic signature is the legal equivalent of your manual signature.
