Maverick Energy, Inc. Questionnaire Page

QUESTIONNAIRE PAGE

We have three ways you may fill out our Purchaser Questionnaire:

Download our Manual Form.
You will download this form, fill it out by hand, then send it in to Maverick at the address below.
This document is best viewed with Microsoft Word 2000.
Download our Digital Form.
You will download this form, fill it out digitally, then send it in to Maverick at the address below, or email.
This document is best viewed with Microsoft Word 2000.

Send Printed Forms to:
Maverick Energy, Inc.
ATTN: Larry Neely, President
P.O. Box 196
Robinson, IL 62454

Fill out our form online.
By filling out this form online, you understand that:

The information contained herein is being furnished to you in order for you to determine whether the undersigned’s Subscription Agreement to purchase an interest (one or more shares) in Maverick Energy, Inc. may be accepted by you in light of the requirements of Section 4 (2) of the Securities Act of 1933, as amended and Rule 504 of Regulation D promulgated thereunder, and an exemption in the securities laws of certain states. The undersigned prospective investor understands the information is needed in order to satisfy various suitability as provided in the Memorandum and Subscription Agreement provided herewith, and that the Investor and/or his or her financial or other advisors (“Purchaser Representative”) has knowledge and experience in financial and business affairs such that the Investor is capable of evaluating the merits and risks of the of the proposed investments. The Investor understands the (a) you will rely on the information herein contained for proposes of such determination; (b) the Shares will not be registered under the Securities Act in reliance upon the exemption form registration afforded by Section 4 (2) of the Securities Act and Rule 504 of Regulation D; (c) the Shares will not be registered under the securities laws of any state in reliance on similar exemptions; and (d) this Questionnaire is not an Offer of shares or any other securities.

The Investor also understands that, although this Questionnaire and the responses provided herein will be kept confidential, you may need to present it to such parties as you deem advisable in order to establish the applicability under any federal or state securities laws of an exemption from registration.

It is in accordance with the foregoing, the following representations and information are hereby furnished.

By clicking the "Submit to Maverick" button, I am signing the form as I would affix my signature to any other physical documentation wherein my signature represents my understanding the format, language and purpose of the document and the information provided in the document.

Confidential Purchaser Questionnaire
Maverick Energy, Inc. (an Illinois Company) Private Placement of Company Interests

Company Name:
ATTENTION:

Gentleman: The information contained herein is being furnished to you in order for you to determine whether the undersigned’s Subscription Agreement to purchase an interest (one or more shares) in Maverick Energy, Inc. may be accepted by you in light of the requirements of Section 4 (2) of the Securities Act of 1933, as amended and Rule 504 of Regulation D promulgated thereunder, and an exemption in the securities laws of certain states. The undersigned prospective investor understands the information is needed in order to satisfy various suitability as provided in the Memorandum and Subscription Agreement provided herewith, and that the Investor and/or his or her financial or other advisors (“Purchaser Representative”) has knowledge and experience in financial and business affairs such that the Investor is capable of evaluating the merits and risks of the of the proposed investments. The Investor understands the (a) you will rely on the information herein contained for proposes of such determination; (b) the Shares will not be registered under the Securities Act in reliance upon the exemption form registration afforded by Section 4 (2) of the Securities Act and Rule 504 of Regulation D; (c) the Shares will not be registered under the securities laws of any state in reliance on similar exemptions; and (d) this Questionnaire is not an Offer of shares or any other securities. The Investor understands that, although this Questionnaire and the responses provided herein will be kept confidential, you may need to present it to such parties as you deem advisable in order to establish the applicability under any federal or state securities laws of an exemption from registration. In accordance with the foregoing, the following representations and information are hereby furnished:

PERSONAL INFORMATION:
Full Name:
Home Address:
City/State/Zip:
Home Phone:
Home Fax:
E-Mail Address:
Social Security #:
BUSINESS INFORMATION:
Business Name:
Mailing Address:
City/State/Zip:
Business Phone:
Business Fax:
Tax Identification #:
Web Site URL:

PLEASE ANSWER ALL QUESTIONS (Choose yes/no, type dates in the spaces provided):

My individual net income (not including my spouse) was in excess of in 20 and 20 .

I anticipate that my individual net income will exceed in 20 .

Our joint income (self and spouse) was in excess of in 20 and 20 .

I anticipate that our joint income will exceed in 20 .

My current total net worth (individual or joint, if married) including real estate, investments, savings, stocks, bonds, pension and profit sharing (including the total current value of home, autos, furnishing and personal belongings) is:

I have invested in other private placements of securities.

yes

FREQUENCY OF PRIOR INVESTMENTS (Check one selection for each column.)

A description of my partnership investments and any other substantial experience in business in business or financial matters that enables me to evaluate the merits and risks of this investment is as follows:

Marketable Securities:

Real Estate:

Oil and Gas Leasing:

Tax Advantaged Investments:

METHOD OF INVESTMENT OF EVALUATION:

Each prospective Investor is required to retain the services of a Purchaser Representative when such prospective Investor does not have sufficient knowledge and experience in financial and business matters to be capable of evaluating the merits and the risk acquiring Share(s). The following is an indication of my knowledge and experience or, alternatively, the necessity of the services of a Purchaser Representative:

(i)

I have such knowledge and experience in financial matters that I am capable of evaluating the merits and risks of an investment in the Share(s) and will not require the services of a Purchaser Representative. I offer as evidence of such knowledge and experience in these matters the information contained in this Questionnaire.

yes

(ii)

I have retained the services of a Purchaser Representative. I acknowledge the following named person(s) to be my Purchaser Representative in connection with evaluating the merits and risks of an investment in the Shares.

yes

Purchaser Representative Name:

The above named Purchaser Representative has furnished to me a completed Purchaser Representative Questionnaire, a copy of which I reviewed prior to signing this Questionnaire and which I am delivering to you here with. I and the above named Purchaser Representative, together, have such knowledge and experience in financial matters that we are capable of evaluating the merits and the risks of an investment in the Share(s).

IF YOU HAVE CHECKED YES UNDER METHOD (ii), THIS QUESTIONNAIRE MUST BE ACCOMPANIED BY ONE COMPLETED AND SIGNED COPY OF THE PURCHASER REPRESENTATIVE QUESTIONNAIRE.

I understand that Maverick Energy, Inc. will rely on the accuracy and completeness of my responses to the foregoing questions and the Investor represents and warrants to Maverick Energy, Inc. as follows:

(i)

The answers to the above questions are complete and correct and may be relied upon by the Company in determining whether the Investor meets the suitability standards for an investors in the Shares;

(ii)

I will notify the Company immediately of any material changes in any statement made herein occurring prior to the closing of any purchase by me of Share of the Company; and

(iii)

I have sufficient knowledge and experience in financial matters to evaluate the merits and risks of the prospective investment and I am able to bear the economic risk of the investments and currently could afford a complete loss of such investment.

IN THE WITNESS WHEREOF, the Investor has executed this Confidential Purchasers Questionnaire, the
day of , and declares that it is truthful and correct.

(Check applicable designation):

Printed Name of Investor

Printed Name of Co-Investor

(i) For unmarried individuals investing jointly, please provide a signed Subscription Agreement for each individual.
(ii) If a custodian, trustee or agent, please include trust, agency or other agreement ad a certificate authorizing investment and legal existence of the Trust.
(iii) If a partnership, please provide a certified copy of the partnership agreement and any amendments thereto. If a limited partnership, please provide, in addition, a certificate of limited partnership as currently in effect.
(iv) If a corporation, please include articles of incorporation and bylaws, as amended and currently in effect, certified corporate resolutions of other documents authorizing the investments, certificate of incumbency of officers and certified of audited financial statements for the proceeding three fiscal years.

By submitting this information to Maverick Energy, Incorporated, I am agreeing to the terms contained herein.

Confidential Purchaser Questionnaire