Self-Directed Custodian
Participant Information
Entity Information
Group Name (If Applicable)
Group Facilitator (If Applicable)
Legal Company Name
First Name
Middle Initial
Last Name
Date of Birth
SSN/ITIN
DBA Name (Doing Business As)
Exact Nature Of Business
Owner Name
Contact Name
Contact Title
Contact Phone
Contact Fax
Company Contact Email
Street Address
Apt/Suite
City
State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other
Country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia, the Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.s. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
Zip Code
Check if Residence
Email
Phone
Language Preference Afrikaans Albanian - shqip Amharic - አማርኛ Arabic - العربية Aragonese - aragonés Armenian - հայերեն Asturian - asturianu Azerbaijani - azərbaycan dili Basque - euskara Belarusian - беларуская Bengali - বাংলা Bosnian - bosanski Breton - brezhoneg Bulgarian - български Catalan - català Central Kurdish - کوردی (دەستنوسی عەرەبی) Chinese - 中文 Corsican Croatian - hrvatski Czech - čeština Danish - dansk Dutch - Nederlands English Esperanto - esperanto Estonian - eesti Faroese - føroyskt Filipino Finnish - suomi French - français Galician - galego Georgian - ქართული German - Deutsch Greek - Ελληνικά Guarani Gujarati - ગુજરાતી Hausa Hawaiian - ʻŌlelo Hawaiʻi Hebrew - עברית Hindi - हिन्दी Hungarian - magyar Icelandic - íslenska Indonesian - Indonesia Interlingua Irish - Gaeilge Italian - italiano Japanese - 日本語 Kannada - ಕನ್ನಡ Kazakh - қазақ тілі Khmer - ខ្មែរ Korean - 한국어 Kurdish - Kurdî Kyrgyz - кыргызча Lao - ລາວ Latin Latvian - latviešu Lingala - lingála Lithuanian - lietuvių Macedonian - македонски Malay - Bahasa Melayu Malayalam - മലയാളം Maltese - Malti Marathi - मराठी Mongolian - монгол Nepali - नेपाली Norwegian - norsk Norwegian Bokmål - norsk bokmål Norwegian Nynorsk - nynorsk Occitan Oriya - ଓଡ଼ିଆ Oromo - Oromoo Pashto - پښتو Persian - فارسی Polish - polski Portuguese - português Punjabi - ਪੰਜਾਬੀ Quechua Romanian - română Romanian (Moldova) - română (Moldova) Romansh - rumantsch Russian - русский Scottish Gaelic Serbian - српски Serbo-Croatian - Srpskohrvatski Shona - chiShona Sindhi Sinhala - සිංහල Slovak - slovenčina Slovenian - slovenščina Somali - Soomaali Southern Sotho Spanish - español Sundanese Swahili - Kiswahili Swedish - svenska Tajik - тоҷикӣ Tamil - தமிழ் Tatar Telugu - తెలుగు Thai - ไทย Tigrinya - ትግርኛ Tongan - lea fakatonga Turkish - Türkçe Turkmen Twi Ukrainian - українська Urdu - اردو Uyghur Uzbek - o‘zbek Vietnamese - Tiếng Việt Walloon - wa Welsh - Cymraeg Western Frisian Xhosa Yiddish Yoruba - Èdè Yorùbá Zulu - isiZulu
Contribution Information
Entity Contribution Information
Initial Amount
Automatic Contribution
Automatic Type Weekly Biweekly Monthly
Automatic Schedule
On every Monday
On every Tuesday
On every Wednesday
On every Thursday
On every Friday
On every Saturday
On every Sunday
Every other Monday
Every other Tuesday
Every other Wednesday
Every other Thursday
Every other Friday
Every other Saturday
Every other Sunday
first day of the month
last day of the month
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
13th
14th
15th
16th
17th
18th
19th
20th
21st
22nd
23rd
24th
25th
26th
27th
28th
29th
30th
31st
Start Date
Statement of Compliance
Signatures
Participant Name
Participant Signature
Date
Identification
IDs required: Government-issued ID (e.g., passport, driver's license, national ID) and proof of address (e.g., utility bill). Check the platform's terms for specifics.
1st Form of Identification
2nd Form of Identification
Beneficiaries
Add a Beneficiary
Verification of Investor Suitability
Verification Documentation (Rule 506(c) Requirement)
Acknowledgement & Signature
By signing below, you certify that the information provided is accurate and complete. You acknowledge that:
I hereby represent and warrant that all information provided above is true, complete, and accurate to the best of my knowledge. I understand that the Company will rely on this information for purposes of determining my eligibility under Regulation D Rule 506(c).
I acknowledge that I may be required to furnish additional documentation to verify my Accredited Investor status and that my investment may be rejected if the Company determines I do not meet the suitability standards.
I hereby attest and affirm that I am a retail investor, and I fully understand the nature and risks associated with investing in private offerings. I acknowledge that I should not invest more than 10% of my annual income or 10% of my net worth, whichever is greater, in this or any similar private investment opportunity.
I understand that investing in private securities involves a high degree of risk and limited liquidity, and there is no guarantee of profit or return of principal. I further acknowledge that it is my responsibility to review the risk disclosures, offering documents, and all related materials, and have had the opportunity to consult with my own financial and legal advisors prior to investing.
By checking this box, I hereby represent, warrant, and certify that all information provided herein is true, complete, and accurate to the best of my knowledge and belief. I further acknowledge and agree that it is my responsibility to read and accept all terms, conditions, disclosures, and representations contained in this questionnaire, PPM (Private Placement Memorandum), and any accompanying materials. I expressly agree to be bound by the conditions set forth herein and acknowledge that any misrepresentation, omission, or false statement may result in the rejection of my participation, the termination of any related agreement, or the pursuit of any remedies available under applicable federal, state, or international law.
Full Name
Signature
Date