Name

Address

City

State

Zip

Phone

Fax

Email Address

Do you fit the SEC definition of an accredited investor?

1. Any natural person whose individual net worth, or joint net worth with that person's spouse, exceeds $1,000,000; or
2. Any natural person who had an individual income in excess of $200,000 in each of the two most recent years or joint income with that person's spouse in excess of $300,000 in each of those years and has a reasonable expectation of reaching the same income level in the current year.
3. 
   Yes No

What is your background/expertise in? (check as many as apply)

Computer Hardware Computer Software Consumer Products Internet Media	Service Companies Retail Medical/Health Care Telecom Distribution	Manufacturing Life Sciences Transportation Finance Education
Other

What particular investment categories interest you? (check as many as apply)

Computer Hardware Computer Software Consumer Products eCommerce Media	Service Companies Retail Medical/Health Care Telecom Distribution	Manufacturing Life Sciences Transportation Financial Services All
Other

What are your investment criteria (stage of development)?
(check as many as apply)

Seed Mezzanine R & D

Turnaround Growth/Preprofit MBOs

Growth/Profitable All

What type of investments do you prefer?
(check as many as apply)

Common Equity Convertible Preferred Stock

Debt None of the above

Convertible Debt All

What is the typical size deal you are looking for?

$0-25,000 $25,001-50,000 $50,001-100,000 $100,000+

How many Angel investments have you made to date?

0 1 - 5 6 - 9 10 +

How many Angel investments might you make per year?

1 2 3 4 5

Do you want an active role in the company?
Yes No

If Yes, what role?

Outside Advisor Board Seat Part-time management Full-time management

In what physical proximity do you prefer to do deals?

Same City Within 1 Hour Within 2 Hours Within Indiana

How would you prefer to “view” deals?

Monthly receptions at the Indiana Venture Center “Webinar” (live presentation simulcast to your personal PC and phone line) Review archived “Webinar” presentation at your leisure Receptions within your region All

How would you prefer the Indiana Venture Center, Inc. communicate with you? Please indicate your preferences by prioritizing them (1 being the highest, 5 being the lowest).

1 2 3 4 5 Email 1 2 3 4 5 Mailings 1 2 3 4 5 Telephone 1 2 3 4 5 Through Assistant 1 2 3 4 5 Fax

Please list any angels/ potential angels we should add to our confidential AngelNet list.