PLEASE ANSWER ALL QUESTIONS. If the appropriate answer is "None" or "Not Applicable," so state. Please print or type your answers to all questions. Attach additional sheets if necessary to complete your answers to any item.
PLEASE ANSWER ALL QUESTIONS. If the appropriate answer is “None” or “Not Applicable”, so state. Please print or type your answers to all questions. Attach additional sheets if necessary to complete your answers to any item. Your answers will be kept strictly confidential at all times. However, Palladium Capital Advisors, LLC (the “Company”) may present this Questionnaire to such parties as it deems appropriate in order to assure itself that the offer and sale of securities of the Company will not result in a violation of the registration provisions of the Securities Act of 1933, as amended, or a violation of the securities laws of any state.
PLEASE ANSWER ALL QUESTIONS. If the appropriate answer is “None” or “Not Applicable”, so state. Please print or type your answers to all questions. Attach additional sheets if necessary to complete your answers to any item. Your answers will be kept strictly confidential at all times. However, Oxysure Systems, Inc. (the “Company”) may present this Questionnaire to such parties as it deems appropriate in order to assure itself that the offer and sale of securities of the Company will not result in a violation of the registration provisions of the Securities Act of 1933, as amended, or a violation of the securities laws of any state.
PLEASE ANSWER ALL QUESTIONS. If the appropriate answer is “None” or “Not Applicable,” so state. Please print or type your answers to all questions. Attach additional sheets if necessary to complete your answers to any item. Your answers will be kept strictly confidential at all times. However, the Company may present this Questionnaire to such parties as it deems appropriate in order to assure itself that the offer and sale of the Notes and Warrants will not result in a violation of the registration provisions of the Securities Act or a violation of the securities laws of any state.
PLEASE ANSWER ALL QUESTIONS. If the appropriate answer is “None” or “Not Applicable,” so state. Please print or type your answers to all questions. Attach additional sheets if necessary to complete your answers to any item. Your answers will be kept strictly confidential at all times; however, the Company may present this Questionnaire to such parties as it deems appropriate, including its counsel, in order to assure itself that the offer and sale of the Units will not result in a violation of the registration provisions of the 1933 Act or a violation of the securities laws of any state.
PLEASE ANSWER ALL QUESTIONS. (If more space is needed, a continuation sheet may be attached.) How were you referred to P-Fleet? ☐ Another Customer ☐ Driver ☐ P-Fleet Rep ☐ Mailer ☐ Google ☐ Yahoo ☐ Other (specify): COMPANY INFORMATION Company Name ☐ LLC ☐ Incorporated ☐ Partnership ☐ Proprietorship State DBA Federal ID # D&B # Industry Physical Address City State Zip Mailing Address City State Zip Years in Business If less than 1 year, previous business name and address: Primary Contact Phone Fax E-Mail Payables Contact Phone Fax E-Mail Has your company ever filed Bankruptcy? ☐ Yes ☐ No If yes, what chapter? Date of Filing BANK INFORMATION Bank Acct # City State Phone Contact Bank Acct # City State Phone Contact BUSINESS CREDIT REFERENCES Fuel Supplier Monthly Gallons City State Phone Fax Vendor City State Phone Fax Vendor City State Phone Fax Does your company own Real Property? ☐ Yes ☐ No If yes, address: OFFICERS OF COMPANY Name Title SS # Home Address City State Zip ☐ Own ☐ Rent Name Title SS # Home Address City State Zip ☐ Own ☐ Rent CONVENIENT PAY ENROLLMENT AND AUTHORIZATION AGREEMENT P-Fleet is hereby authorized to pay and charge Customer’s account electronically for properly supported charges due and owing P-Fleet only. This authorization will remain in effect until revoked by Customer in writing, and until such notice is actually received, Financial Institution will be fully protected in honoring any such electronic transfer. This Agreement allows P-Fleet to charge debits to Customer’s account at frequent intervals for varying amounts. It is acknowledged and accepted that the debits owed to P-Fleet will typically be paid on the due date or next business day. P-Fleet will notify Customer by fax of any and all impending debits. THERE WILL BE A $50 CHARGE BY P-Fleet FOR ANY ELECTRONIC TRANSFER RETURNED UNPAID. In the event a debit is shown to be made erroneously, P-Fleet agrees to correct such error immediately. Financial Institution Name Branch Phone Bank Routing # Checking Acct # Signature X Print Name Title Date TERMS AND CONDITIONS The Customer fully understands and agrees to comply with the following terms and conditions of this Agreement.
PLEASE ANSWER ALL QUESTIONS. (If more space is needed, a continuation sheet may be attached.) How were you referred to P-Fleet? ☐ Another Customer ☐ Driver ☐ P-Fleet Rep ☐ Mailer ☐ Google ☐ Bing ☐ Other (specify): COMPANY INFORMATION Company Name ☐ LLC ☐ Incorporated ☐ Partnership ☐ Proprietorship State DBA Federal ID # D&B # Industry Physical Address City State Zip Years in Business Has your company ever filed Bankruptcy? ☐ Yes ☐ No If yes, what chapter? Date of Filing Primary Contact Phone Fax E-Mail Fuel Supplier Monthly Fuel Spend City State Phone Fax
PLEASE ANSWER ALL QUESTIONS. If the appropriate answer is "None" or "Not Applicable" so state. Please print or type your answers to all questions. Attach additional sheets if necessary to complete your answers to any item. Your answer will be kept strictly confidential at all times; however, the Company may present this Questionnaire to such parties as it deems appropriate in order to assure itself that the offer and sale of the Securities will not result in a violation of federal securities laws or the securities laws of any state.
PLEASE ANSWER ALL QUESTIONS. If the appropriate answer is "None" or "Not applicable," please so state. Please print or type your answer to all questions. Attach additional sheets if necessary to complete your answers to any item. N/A SECTION A GENERAL INFORMATION (All Investors must Complete this Section) COMPLETE ITEMS 4 AND 5 FOR TENANTS IN COMMON AND JOINT TENANTS ONLY IF THE -------------------------------------------------------------------------- INFORMATION DIFFERS FROM THAT GIVEN ABOVE. ------------------------------------------
PLEASE ANSWER ALL QUESTIONS. If the appropriate answer is “None” or “Not Applicable”, so state. Attach additional sheets if necessary to complete your answers to any item. The undersigned makes the following representations and warranties:
