Form-SEC Form D – Reg D Filer

Form D

SEC Form D filing information

Company Name(Required)

Related Person(Required)

First Middle Last

Address

Due to the Form D being public information, we recommended you use the business address

Use Business Address (From Form ID)

Add an Address

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship(s):(Required)

Executive Officer

Director

Promoter

Add additional related persons

Yes

Related Person

First Middle Last

Address

Due to the Form D being public information, we recommended you use the business address

Use Business Address (From Form ID)

Add an Address

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship(s):(Required)

Executive Officer

Director

Promoter

Add additional related persons

Yes

Related Person

First Middle Last

Address

Due to the Form D being public information, we recommended you use the business address

Use Business Address (From Form ID)

Add an Address

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship(s):(Required)

Executive Officer

Director

Promoter

Add additional related persons

Yes

Related Person

First Middle Last

Address

Due to the Form D being public information, we recommended you use the business address

Use Business Address (From Form ID)

Add an Address

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship(s):(Required)

Executive Officer

Director

Promoter

Add additional related persons

Yes

Related Person

First Middle Last

Address

Due to the Form D being public information, we recommended you use the business address

Use Business Address (From Form ID)

Add an Address

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship(s):(Required)

Executive Officer

Director

Promoter

If additional Related Persons, please list below)

Industry Group

(Select one)(Required)

Banking and Financial Services(Required)

Fund Type(Required)

Hedge Fund

Private Equity Fund

Venture Capital Fund

Other Investment Fund

Is the issuer registered as an investment company under the Investment Company(Required)

Yes

Energy(Required)

Health Care(Required)

Real Estate(Required)

Technology(Required)

Travel(Required)

Issuer Size

Revenue Range (for issuer not specifying "hedge" or "other investment" fund)(Required)

No Revenues

$1 - $1,000,000

$1,000,001 - $5,000,000

$5,000,001 - $25,000,000

$25,000,001 - $100,000,000

Over $100,000,000

Decline to Disclose

Not Applicable

Aggregate Net Asset Value Range (for issuer specifying "hedge" or "other investment" fund)(Required)

No Aggregate Net Asset Value

$1 - $5,000,000

$5,000,001 - $25,000,000

$25,000,001 - $50,000,000

$50,000,001 - $100,000,000

Over $100,000,000

Decline to Disclose

Not Applicable

Federal Exemptions and Exclusions Claimed

(Select all that apply)(Required)

Rule 504(b)(1) (not (i), (ii) or (iii))

Rule 504(b)(1)(i)

Rule 504(b)(1)(ii)

Rule 504(b)(1)(iii)

Rule 506(b)

Rule 506(c)

Securities Act Section 4(a)(5)

Investment Company Act Section 3(c)

Type of Filing

Type of Filing(Required)

New Notice

Amendment

Date of First Sale in this Offering

If First Sale Yet to Occur leave blank

Duration of Offering

Does the issuer intend this offering to last more than one year?(Required)

Yes

Type(s) of Securities Offered

(Select all that apply)(Required)

Equity

Debt

Option, Warrant or Other Right to Acquire Another Security

Security to be Acquired Upon Exercise of Option,Warrant or Other Right to Acquire Security

Pooled Investment Fund Interests

Tenant-in-Common Securities

Mineral Property Securities

Other (describe)

(describe)(Required)

Business Combination Transaction

Is this offering being made in connection with a business combinationtransaction, such as a merger, acquisition or exchange offer?(Required)

Yes

Clarification of Response (if necessary)

Minimum Investment

Minimum investment accepted from any outside investor(Required)

Sales Compensation

Are you using a Broker/Dealer?(Required)

Yes

Broker/Dealer(Required)

Please provide the name, address and CRD number for the Broker/Dealer and any Associated Broker/Dealer

States of Solicitation

Offering and Sales Amounts

Total Offering Amount

Indefinite (amount not limited)

Yes

Total Amount Sold(Required)

Total Remaining to be Sold

Sold(Subtract (a) from (b))

Clarification of Response (if necessary)

Investors

Select if securities in the offering have been or may be sold to persons who do not qualify as accredited investors, and enter the number of such non-accredited investors who already have invested in the offering:

Yes

Total Non-Accredited Investors(Required)

Regardless of whether securities in the offering have been or may be sold to persons who do not qualify as accredited investors, enter the total number of investors who already have invested in the offering:(Required)

Sales Commissions and Finders' Fees Expenses

Provide separately the amounts of sales commissions and finders' fees expenses, if any. If the amount of an expenditure is not known, provide an estimate and check the box next to the amount.

Sales Commissions(Required)

Estimate

Yes

Finders' Fees(Required)

Estimate

Yes

Clarification of Response (if necessary)

Use of Proceeds

Provide the amount of the gross proceeds of the offering that has been or is proposed to be used for payments to any of the persons required to be named as executive officers, directors or promoters in response to Item 3 above. If the amount is unknown, provide an estimate and check the box.(Required)

Estimate

Yes

Signer

Name of Signer(Required)

Title(Required)