OKLAHOMA DEPARTMENT OF SECURITIES
204 North Robinson, Suite 400
Oklahoma City, Oklahoma 73102

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.

INFORMATION ABOUT YOU:

Mr. or Ms.________________________________________________________________ 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 (____)_________

Address __________________________ City _______________ ST ____ Zip______ Phone (____)_________

Salesperson __________________________ Position _________________________  Phone (____)_________

Other ________________________________ Position _________________________ Phone (____)_________

Other ________________________________ Position _________________________ Phone (____)_________

Other ________________________________ Position _________________________ Phone (___)__________

 

 

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

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________


INFORMATION ABOUT THE OFFER:

  1. How was the offer to invest/purchase made: (Check One) (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? No Yes When did you invest? _____________ Amount invested $________

  3. How did you pay? Cash Check (attach a copy--Front & Back) Other____________________

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

  5. Did you sign any type of contract? No Yes (attach a copy) Date signed _____________________

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

  7. Do you know any other purchasers? No Yes (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? No Yes If Yes, please identify:

    a. ________________________________________________________________________________

    b. ________________________________________________________________________________

    c. ________________________________________________________________________________

     

  2. Have you hired an attorney? No Yes 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?

    No
    Yes

     

  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?

    No
    Yes

     

  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?

    No
    Yes


    Signature ________________________________________________ Date __________________

    Signature ________________________________________________ Date __________________