First Name:

*

Last Name:

*

Company Name:

Street Address:

*

City:

*

State / Province:

Select State or Province Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Colorado Connecticut Delaware District Of Columbia Fed. States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Oregon Prince Edward Island Province du Quebec Puerto Rico Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory *

Zip / Postal Code:

*

Country:

Select Country United States Canada Argentina Australia Austria Bahamas Belgium Bolivia Brazil Chile China Colombia Costa Rica Croatia Cuba Czech, Rep. Denmark Dominican, Rep. Ecuador Egypt El Salvador Finland France Germany Greece Guatemala Honduras Hong Kong India Ireland Israel Italy Jamaica Japan Luxembourg Mexico Morocco Netherlands New Zealand Nicaragua Nigeria Norway Paraguay Peru Poland Portugal Puerto Rico Russia Saudi Arabia South Africa Spain Sweden Switzerland Taiwan Turkey United Kingdom Uruguay Venezuela Other... *

Work Phone:

*

Home Phone:

*

Fax:

E-Mail Address:

*

Education Experience

My Formal Education (School / Degree / Year Received)

Degree One:

Degree Two:

Degree Three:

I have one of the following licenses:

None Series 3 Series 4 Series 5 Series 6 Series 7 Series 9 Series 10 Series 11 Series 15 Series 22 Series 24 Series 26 Series 27 Series 28 Series 30 Series 31 Series 32 Series 33 Series 39 Series 42 Series 52 Series 62 Series 63 Series 65 Series 66 Series 72

Do you believe that you have sufficient knowledge and experience in financial and business matters to evaluate the merits and risks of oil and gas partnerships?

Yes     No     *

Investment Information

U.S. Persons:  Are you or are you acting for a U.S. Person? (A US person is defined as an individual who is a national or permanent resident alien of the US and any corporation, business association, partnership, trust, or other judicial entity incorporated or permanently residing in the U.S.)

Yes     No     *

Accredited Investors (Choose A or B)

A. Individual Investors:Are you, in your capacity as an individual, rather than as an agent of a legal entity, an accredited investor?

Yes     No     *    

See below for a definition of an "Accredited Investor".

B. Entities: Are you an agent of a legal entity that is an accredited investor?

Yes     No     *

See below for a definition of an "Entity" which is an "Accredited Investor".

Qualified Purchaser: Are you or are you acting for a "qualified purchaser"?

Yes     No     *

See below for a definition of a "Qualified Purchaser".

What is your individual or joint total net worth? (May be combined with your spouse)

Select one... Less than $500,000 $500,000 - $1 Million $1 Million - $2 Million $2 Million - $4 Million $4 Million - $5 Million $5 Million - $10 Million $10 Million and above

See below for a definition of "Net Worth".

Annual Earnings:

2000: Less than $200,000   $200,000 or more

2001: Less than $200,000   $200,000 or more

2002: Less than $200,000   $200,000 or more

See below for a definition of "Annual Earnings".

Current Investments:

Hedge Fund:

$          

Stocks:

$       

Bonds:

$         

Mutual Funds:

$         

Gold / Silver:

$          

Commodities:

$          

If Financial Intermediary, which of the following are you?

Select one... Independent Registered Investment Advisor RIA associated with Broker/Dealer

How many years experience investing in oil and gas partnerships do you or your clients have?

Select one... None 1 - 5 years 6 or more years

By electronically signing below, I am affirming that all the information contained herein is true and correct to the best of my knowledge and belief.

Electronic Signature:

*

*Asterisk indicates required field

Annual Earnings:

Annual earnings” means adjusted gross income, as reported for federal income tax purposes, less any income attributable to a spouse, increased by the following amounts (but not including any amounts attributable to a spouse or to property owned by a spouse), (i) the amount of any tax exempt interest income received;
(1) the amount of any losses claimed as a partner in a partnership;
(2) any deductions claimed for depletion;
(3) amounts contributed to an ira or keogh retirement plan;
(4) alimony paid; and
(5) any amount by which income from long-term capital gains has been reduced in arriving at adjusted gross income pursuant to the provisions of section 1202 of the internal revenue code of 1954, as amended.

Accredited Investor:

You are an accredited investor if any one of the following are true:
1) Your individual net worth, or joint net worth with spouse, at the time of this purchase exceeds $1,000,000.
2) You had an individual income in excess of $200,000 in each of the two most recent years and reasonably expect an income in excess of $200,000 in the current year.
3) You and your spouse have had joint income for the most two recent years in excess of $300,000 and expect your joint income to be in excess of $300,000 for the current year.

Net Worth:

The fair market value of all assets, excluding home, furnishings and personal automobiles.

Qualified Purchaser:

The fair market value of all assets, including home, furnishings and personal automobiles is or exceeds $500,000.