This Standard Document is a form of Purchaser Representative Questionnaire for use by a company in an unregistered offering under Rule 506(b) of Regulation D. This questionnaire is used in a company's private placement of securities to help collect and verify information relating to the purchaser representative(s) of potential investors about which neither the company nor, if applicable, the placement agent has sufficient knowledge to determine on its own. If a potential investor is using a purchaser representative to qualify for the offering, this questionnaire must be sent out to the purchaser representative to verify that the person or entity acting as purchaser representative is qualified to do so. This Standard Document has integrated notes with important explanations and drafting tips.