INTERNATIONAL ENERGY NETWORK FORM

Individual Investors

Name:
Street Address:
City State/Province
Country:
Postal Code:
Telephone: Fax:
Have you invested in oil and gas before? Yes No
What is your primary interest? Safety of capital
Income
Long-term gain
What amount are you seeking to invest?

International Energy Network
1202 Richardson Drive, Suite 309
Richardson, TX 75080
e-mail address: info@internationalenergy.com