Vascular BioSciences Accredited Investor

For Accredited Investors

Vascular BioSciences respects the privacy of prospective investors. Information will be held in the strictest confidence, and will not be sold, transferred or distributed.

Information regarding private placements available from Vascular BioSciences shall be forwarded to qualified investors only by e-mail unless another means of written verification is requested and agreed to between Vascular BioSciences and the respective qualified investor.

Please register to receive further information.

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Personal Information:

* Last Name:
Middle Initial:
* First Name:

Age:
* Date of Birth:

Company
Position / Title:
* Your E-mail Address:

* Residential Address:

* City:
* State:
* Zip Code:

* Country:

* Business Address:

* City:
* State:
* Zip Code:

* Country:

To participate as an investor qualified as an "Accredited Investor" under the United States securities laws and to be able to participate in private placements available from Vascular BioSciences, you must establish your status as an accredited investor by answering the following questions that apply to your description.

1. Do you or your spouse have a combined net worth of $1 million or more?
No
Yes

2. For each of the past two years has your annual income been greater than or equal to $200,000 or has the combined annual income of you and your spouse been greater than or equal to $300,000?
No
Yes

3. Do you anticipate your income will continue at this level?
No
Yes

4. Is this an account for a trust or business partnership with assets in excess of $5 million, that was not formed for the purpose of acquiring unregistered securities?
No
Yes

5. Is the investor for which you seek registration an entity wholly-owned by "accredited investors"?
No
Yes

6. Are you an officer of and investing on behalf of a firm which is a financial institutional, such as a bank, savings and loan association, insurance company, registered investment company, broker/dealer organization, employee benefit/retirement plan, business development company, or a Small Business Investment Company ("SBIC")?
No
Yes

Sign this Questionnaire
To return this Questionnaire through the Vascular BioSciences link,
please enter your full name on the signature line.

The foregoing statements are true and accurate to the best of my information and belief and I will promptly notify Vascular BioSciences of any changes in the foregoing answers.

* Full Name:
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* Date:
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