Personal Information  
                  
                 
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                   First Name  
                    
                  
                 
                   Last Name  
                    
                  
                 
                   Job Title  
                    
                  
                 
                   Company Name 
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                   E-mail Address  
                    
                  
                 
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                   City  
                    
                  
                 
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                   Country of Residence  
                   
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                       Afghanistan 
                       Albania 
                       Algeria 
                       American Samoa 
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                       Antarctica 
                       Antigua and Barbuda 
                       Argentina 
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                       Aruba 
                       Australia 
                       Austria 
                       Azerbaijan 
                       Bahamas 
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                       Bangladesh 
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                       Belarus 
                       Belgium 
                       Belize 
                       Benin 
                       Bermuda 
                       Bhutan 
                       Bolivia 
                       Bosnia and Herzegovina 
                       Botswana 
                       Brazil 
                       Brunei 
                       Bulgaria 
                       Burkina Faso 
                       Burundi 
                       Cambodia 
                       Cameroon 
                       Canada 
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                       Cayman Islands 
                       Central African Republic 
                       Chad 
                       Chile 
                       China 
                       Christmas Island 
                       Cocos (Keeling) Islands 
                       Colombia 
                       Comoros 
                       Congo 
                       Cook Islands 
                       Costa Rica 
                       Cote D'Ivoire 
                       Croatia 
                       Cuba 
                       Cyprus 
                       Czech Republic 
                       Denmark 
                       Djibouti 
                       Dominica 
                       Dominican Republic 
                       East Timor 
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                       Equatorial Guinea 
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                       Gabon 
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                       Laos 
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                       Liberia 
                       Libya 
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                       Lithuania 
                       Luxembourg 
                       Macau 
                       Macedonia 
                       Madagascar 
                       Malawi 
                       Malaysia 
                       Maldives 
                       Mali 
                       Malta 
                       Marshall Islands 
                       Martinique 
                       Mauritania 
                       Mauritius 
                       Mexico 
                       Micronesia, Federated States of 
                       Moldova 
                       Monaco 
                       Mongolia 
                       Montserrat 
                       Morocco 
                       Mozambique 
                       Myanmar 
                       Namibia 
                       Nauru 
                       Nepal 
                       Netherlands 
                       Netherlands Antilles 
                       New Caledonia 
                       New Zealand 
                       Nicaragua 
                       Niger 
                       Nigeria 
                       Niue 
                       Norfolk Island 
                       Northern Mariana Islands 
                       Norway 
                       Oman 
                       Pakistan 
                       Palau 
                       Panama 
                       Papua New Guinea 
                       Paraguay 
                       Peru 
                       Philippines 
                       Pitcairn 
                       Poland 
                       Portugal 
                       Puerto Rico 
                       Qatar 
                       Reunion 
                       Romania 
                       Russian Federation 
                       Rwanda 
                       Saint Kitts and Nevis 
                       Saint Lucia 
                       Saint Vincent and the Grenadines 
                       Samoa 
                       San Marino 
                       Sao Tome and Principe 
                       Saudi Arabia 
                       Senegal 
                       Seychelles 
                       Sierra Leone 
                       Singapore 
                       Slovakia 
                       Slovenia 
                       Solomon Islands 
                       Somalia 
                       South Africa 
                       Spain 
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                       Sudan 
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                       Sweden 
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                       Syria 
                       Taiwan 
                       Tajikistan 
                       Tanzania 
                       Thailand 
                       Togo 
                       Tokelau 
                       Tonga 
                       Trinidad and Tobago 
                       Tunisia 
                       Turkey 
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                       Turks and Caicos Islands 
                       Tuvalu 
                       Uganda 
                       Ukraine 
                       United Arab Emirates 
                       United Kingdom 
                       United States 
                       Uruguay 
                       Uzbekistan 
                       Vanuatu 
                       Venezuela 
                       Vietnam 
                       Virgin Islands (British) 
                       Virgin Islands (U.S.) 
                       Western Sahara 
                       Yemen 
                       Yugoslavia 
                       Zaire 
                       Zambia 
                       Zimbabwe 
                       
                  
                 
                   Telephone (incl. international code)  
                      
                         Work   Home  
                  
                 
                   Fax (incl. international code)  
                    
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                   Best time to contact you  
                    
                  
                 
                   Type of Investor  
                   
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                       Individual Investor 
                       Corporate Investor 
                       Private Equity 
                       VC 
                       Other (e.g. Bank, Fund) 
                       
                  
                 
                   Ideal Investment Size  
                   
                       Please select 
                       under $50,000 
                       $50,000 to $100,000 
                       $100,000 to $250,000 
                       $250,000 to $500,000 
                       $500,000 to $1,000,000 
                       $1,000,000 to $2,000,000 
                       over $2,000,000 
                       
                  
                 
                   What type of financings will you consider? 
                       (Please check all that apply)  
                   
                       Seed Level 
                           Start-up 
                           Emerging 
                           Pre IPO 
                       
                    
                  
                 
                   To what extent are you prepared to take a hands-on role?  
                    
                  
                 
                   Which areas are of specific interest?  
                   
                       Exploration Drilling 
                           Development Drilling 
                           Production Acquisition 
                           Land Acquisition 
                           Infrastructure and Facilities 
                           Services Companies 
                           Other:
                    
                  
                 
                   Please describe the level of risk you are willing to consider.  
                    
                  
                 
                   Who referred you to ApecTec?  
                    
                  
                 
                   From what company?