OKLAHOMA DEPARTMENT OF SECURITIES
First National Center, Suite 860
120 North Robinson
Oklahoma City, Oklahoma 73102
Telephone: (405)280-7700 Fax: (405)280-7742

QUESTIONNAIRE

INSTRUCTIONS:
  • Type or print legibly.
  • Make copies of pertinent information. Do Not Send Originals! Please copy front and back of all checks.
  • Be specific when describing dates, times, persons, and what statements were made.
  • If you need more space for an answer, provide the information on additional paper.

Mr. or Ms.  Name   DOB:

Address
        City ST Zip Phone

Place of Employment Trade/Occupation

Address
        City ST Zip Phone

Spouse/Partner's Name Trade/Occupation


INFORMATION ABOUT THE SELLER:

Business Name
                                 Phone #1                          Phone #2

Address
        City   ST Zip

Salesperson Position Phone

Other Position Phone

Other Position Phone

Other Position Phone

Did you know the salesperson/company prior to this investment?  Yes/No
If Yes, please explain:

INFORMATION ABOUT THE OFFER:
  1. How was the offer to invest/purchase made: (Attach copies of documents)
    • Telephone - Who Called & Date
    • Personal Visit - Who Visited & Date
    • Seminar or Group Sales Presentation - Location & Date
    • Newspaper/Magazine - Name & Date
    • Other: Explain (Include date)

  2. Where was the offer made?

  3. Who made the offer? Position

  4. Who else was present? (Name, Address, City, State, Zip Code, Telephone)



INFORMATION ABOUT THE INVESTMENT:
  1. Describe the investment offered to you: (Example: Common Stock, Oil and Gas interests, etc.)

  2. Did you invest? Yes/No  When did you invest?   Amount invested $

  3. How did you pay? (Cash Check)    Other

  4. How much did you purchase? (Example: 1000 Shares; 5% Working Interest, etc.)

  5. Did you sign any type of contract? Yes/No         Date signed

  6. Where was the contract signed/money paid? (City/State)

  7. Do you know any other purchasers? Yes/No
    (Name, Address, City, State, Zip Code, Telephone)



  8. What were you told about the investment?

  9. What untrue statements, if any, were made to you?

  10. What facts, if any, did the seller omit to tell you which would have changed your decision to invest?

INFORMATION ABOUT YOUR COMPLAINT:

  1. Have you communicated with any other state or federal agency?  Yes/No
    If Yes, please identify:
    a.
    b.
    c.  

  2. Have you hired an attorney? Yes/No
    If Yes, please identify: (Name/Address/Telephone)

  3. Describe your past and current investment experience: (Example: Savings Account, Mutual Funds, Oil & Gas interests, etc.)

  4. Are you willing to testify in an administrative hearing or court of law regarding this case?
    Yes/No

  5. Are you willing to permit the Oklahoma Department of Securities to share information from this Questionnaire with other government departments and/or law enforcement agencies?
    Yes/No  

  6. Are you willing to permit the Oklahoma Department of Securities to share information from this Questionnaire to the firm or party your complaint is against in order to resolve the conflict?
    Yes/No  


    Signature ________________________________________________ Date __________________

    Signature ________________________________________________ Date __________________