NJ Intrastate Offering (Crowdfunding) Investor Certification Form {NJBOS Form 12}

NJBOS Form 12 NEW JERSEY INTRASTATE OFFERING (CROWDFUNDING) INVESTOR CERTIFICATION FORM I, ____________, certify that I am a New Jersey resident and have read the following and understand: The securities herein are a high-risk speculative business venture and involve a high degree of risk and should not be purchased by me if I cannot afford the loss of my entire investment. ____________ {initial} The securities herein have not been registered under Uniform Securities Law, P.L. 1967, c. 93 (N.J.S.A. 49:3-47 et seq., the Securities Act of 1933, as amended (the "Securities Act"), or any other applicable law, and are being offered and sold in reliance on exemptions from the registration requirements of these laws. ___________ {initial} The securities herein have not been reviewed or approved by the New Jersey Bureau of Securities, the Securities and Exchange Commission, or any other securities regulatory authority. ____________ {initial} Neither the New Jersey Bureau of Securities, the Securities and Exchange Commission, nor any other securities regulatory authority has passed upon or endorsed the merits of this offering or the accuracy or adequacy of the information on this, or any, website offering and/or selling {insert issuer's name}'s securities. ____________ {initial} The securities are illiquid, there is no ready market for the sale of the securities, and it may be difficult or impossible to sell or otherwise dispose of the investment in the absence American LegalNet, Inc. www.FormsWorkFlow.com of an effective registration statement under the New Jersey Uniform Securities Law, the Securities Act, and any other applicable state securities laws. ___________ {initial} I may be subject to tax on the taxable income and losses of the company. _____ {initial} The New Jersey Bureau of Securities, an arm of the Office of the New Jersey Attorney General, is charged with protecting investors from investment fraud, and regulating the securities industry in New Jersey. Investors should contact the New Jersey Bureau of Securities to research the background of current and former financial professionals before they invest. To research a financial professional, contact the New Jersey Bureau of Securities via phone at 1-866-I-Invest (within New Jersey) or 973-504-3600 (both within and outside New Jersey) or via email at njbos@dca.lps.state.nj.us. _____ {initial} Investors can file a complaint with the New Jersey Bureau of Securities against individuals and firms selling securities or offering investment advice, as well as companies issuing securities investments directly by visiting the www.njsecurities.gov. _______ {initial} Bureau's website at I certify that I have read and understand the above _________________________________________ ____________________ Name Signature ______ Date American LegalNet, Inc. www.FormsWorkFlow.com