This is a Heller Ehrman form that can be used for Risk Management.
INVESTMENT QUESTIONNAIRE (Please print or type) Name of Attorney: Date of Report: Name of Client: Date of Proposed Investment or Disposition: Dollar Amount to be Invested or Received: $___________ Specify terms if other than Cash: Type of Security Acquired or to be Disposed of: Number of Shares or Units Acquired or to be Disposed of: Nature of Acquisition Transaction Being Submitted for Approval (for example, purchase, exchange, etc.): Nature of Disposition Transaction Being Submitted for Approval e.g. Sale, Exchange, Etc.: Special Terms and Conditions (not available to other investors, for example, puts, calls, restrictions on participation, registration rights, rights of first refusal): Percent of Investing Attorney's Net Worth Represented (a) by Proposed Investment: _________%, (b) By Aggregate of all Investing Attorney's Investments in Client (including proposed Investment): ________%, (c) by Proposed Disposition: _______% Percent of Client's Outstanding Voting or Controlling Equity Represented by Investing Attorney's Aggregate Holdings in Client (a) Prior to Proposed Transaction: ________%, (b) After Proposed Transaction ________% If Quoted on a Public Exchange, Most Recently Quoted Price on Publicly Traded Exchange: $_________ If Not Quoted on Public Exchange, Most Recent Price Known to Investing Attorney: $_________ Any Special Knowledge of Client's Affairs Possessed by Investing Attorney or Known by Such Investing Attorney to be Within Knowledge of Firm: Nature of Legal Work Being Performed for Client by Investing Attorney and By Firm: Names of Any Other Investors in Client Who Are Partners or Employee Attorneys of Heller Ehrman and Are Known to Investing Attorney: Specify Nature, Amount and Method of Determination of Price for Simultaneous Investments in or Disposition of Client Securities by Outsiders Who Are Not Connected With Heller, Ehrman, White & McAuliffe: C:\Documents and Settings\tmacentee\My Documents\Template Development\PENDING\Forms Library Migration\PDF\Risk Management\Investment Questionnaire.doc 10/17/06 1:20 PM (99999.9096) 2