Thank you for your interest in Pangea Exploration. Please complete
the questionnaire below. You will be notified by a representative
from Pangea Exploration should you qualify as an accredited investor
and/or a qualified purchaser.
Contact Information
First Name:
*
Last Name:
*
Company Name:
Street Address:
*
City:
*
State / Province:
*
Zip / Postal Code:
*
Country:
*
Work Phone:
* 555-555-5555
Home Phone:
* 555-555-5555
Fax:
555-555-5555
E-Mail Address:
*
I have one of the following
licenses:
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 or joint ventures?
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 *
B. Entities: Are you an agent of a
legal entity that is an accredited investor?
Yes
No *
Qualified Purchaser: Are you or are
you acting for a "qualified purchaser"?
Yes
No *
What is your individual or joint
total net worth? (May be combined with your spouse)
Annual
Earnings:
2004:
Less than $200,000
$200,000 or more
2005:
Less than $200,000
$200,000 or more
2006:
Less than $200,000
$200,000 or more
Current Capital Available to Invest :
$50,000 to $100,000
$100,000 to $200,000
$500,000 to $1,000,000
$1,000,000 to
$5,000,000
$5,000,000 to $10,000,000
$10,000,000 or more
If Financial Intermediary, which of
the following are you?
How many years experience investing
in oil and gas partnerships do you or your clients have?
Tell us about yourself and your company in the
space provided below. Including, any questions, comments, messages or information
you would like to provide.
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.