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
13355 Noel Road, Suite 500 Dallas, TX. 75240
phone (972) 931-3171 fax (972) 931-0608