NJBOS Form 12
NEW JERSEY INTRASTATE OFFERING (CROWDFUNDING)
INVESTOR CERTIFICATION FORM
I, ____________, certify that I am a New Jersey resident and have read the following and
understand:
☐ The securities herein are a high-risk speculative business venture and involve a high
degree of risk and should not be purchased by me if I cannot afford the loss of my entire
investment. ____________ {initial}
☐ The securities herein have not been registered under Uniform Securities Law, P.L. 1967,
c. 93 (N.J.S.A. 49:3-47 et seq., the Securities Act of 1933, as amended (the “Securities
Act”), or any other applicable law, and are being offered and sold in reliance on exemptions
from the registration requirements of these laws. ___________ {initial}
☐ The securities herein have not been reviewed or approved by the New Jersey Bureau of
Securities, the Securities and Exchange Commission, or any other securities regulatory
authority. ____________ {initial}
☐ Neither the New Jersey Bureau of Securities, the Securities and Exchange Commission,
nor any other securities regulatory authority has passed upon or endorsed the merits of this
offering or the accuracy or adequacy of the information on this, or any, website offering
and/or selling {insert issuer’s name}’s securities. ____________ {initial}
☐ The securities are illiquid, there is no ready market for the sale of the securities, and it
may be difficult or impossible to sell or otherwise dispose of the investment in the absence
