Whatcom Opportunities Regional Center (WORC) - Preliminary Investor Questionnaire Online Version

Preliminary Investor Questionnaire - Online Version (click here for FAX version)

THIS FORM IS IMPORTANT! IT SHOULD BE COMPLETED AS FULLY AS POSSIBLE BY OR FOR THE INDIVIDUAL SEEKING ADMISSION TO THE U.S. OR WISHING TO REMAIN HERE. THIS INFORMATION IS FOR USE IN OUR OFFICE ONLY AND WILL BE KEPT STRICTLY CONFIDENTIAL.

Referred by:
What would you like us to do for you?

1.
SURNAME:
FIRSTNAME:
MIDDLENAME:
2.
Address: (Number and Street)
City/Town:
Province:
Country:
Postal Code:
3.
Tel:	(xxx) xxx-xxxx
Email:
4.
BIRTHDATE:	Month / Date / Year
CITY OF BIRTH:
COUNTRY OF BIRTH:
5.
PASSPORT FROM (Country):
PASSPORT NUMBER:
PASSPORT EXPIRATION:
6.
MARITAL STATUS:
Name of Spouse:	(if wife, also give maiden name)
Birthdate of Spouse:	Month / Date / Year
Date of Marriage:	Month / Date / Year
Place of Marriage:
7. FINANCIAL BACKGROUND (for purposes of qualifying for immigration)
Your Net Worth:	US$
Your Liquid Assets:	US$
Your Annual Income for the past 3 (three) years:	Year	Annual Income	Income form both you and your spouse (if applicable)
		US$	US$
		US$	US$
		US$	US$
8. PERSONAL BACKGROUND (for purposes of qualifying for immigration)
Have you, your spouse, or your children ever been:
a. treated for a mental disorder, mental retardation, drug addiction, or alcoholism?			Yes No
b. arrested, convicted, or confined in a prison?			Yes No
c. the beneficiary of a pardon, amnesty, rehabilitation decree, or other act of clemency or similar action?			Yes No
d. convicted of any crime either in the U.S. or anywhere in the world? (excluding minor traffic offenses)			Yes No
e. involved with the illegal use or trafficking of any drugs, narcotics, or marijuana in the U.S. or anywhere?			Yes No
f. a member of a Communist or totalitarian party?			Yes No
g. engaged in prostitution in the U.S. or anywhere in the world?			Yes No
h. given assistance to other aliens to come to the U.S. illegally?			Yes No
i. Are you or your spouse able to support yourselves and your children in the U.S.?			Yes No
j. Have you, your spouse, or children ever had TB or other contagious diseases?			Yes No
9.
Have you or your spouse ever applied for permanent resident status?			Yes No
If yes, when and where did you apply and what was the final disposition?
10.
Have you or your spouse ever been the subject of a deportation proceeding?			Yes No
If yes, when and where did you apply and what was the final disposition?
11.
Other Relevant Information:
THIS FORM IS IMPORTANT! IT SHOULD BE COMPLETED AS FULLY AS POSSIBLE BY OR FOR THE INDIVIDUAL SEEKING ADMISSION TO THE U.S. OR WISHING TO REMAIN HERE. THIS INFORMATION IS FOR USE IN OUR OFFICE ONLY AND WILL BE KEPT STRICTLY CONFIDENTIAL.

This is not a solicitation of investment. Before considering making an investment interested parties should review with the advisors of his/her choice the specific terms of investment contained in the New WORC Development and Management LLC, Operating Agreement and other project documentation.