Survey Form

Inquiry related to:*

Please select one of the options below:

Name*

First Last

Company name*

Website

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Mobile*

Email*

Type of Ownership / Holding / Interest

When did you acquire the above referenced share holding or interest?

How did you acquire your shares or other interest in the Company?

Are these holdings, shares or interests held by you in physical certificate form or held electronically (i.e. brokerage firm / DTC)

Physical Certificate(s)
Electronically (DTC)

How many shares of the above referenced holding do you own?

In the event the Company established a Repurchase Program, would you be interested in a repurchase of your interest or holdings?

Yes
No

If YES, would you be interested in the repurchase of your entire holding/interest or a partial amount?

Entire Holding / Interest
Partial Holding / Interest

If Partial, how many shares would you be interested in being repurchased?

Have you ever received an official mailing from Native American Energy Group, Inc.?

Yes
No

In the event the Company establishes a Share Repurchase Program and there is mutual interest in discussing a “Privately Negotiated Purchase”, how would you prefer a company representative or their attorney contact you?

Email
Home Phone
Work Phone
Mobile

Message*

Additional information such as origins of investment, special circumstances and considerations can be provided above.

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Survey Form

Preliminary Informational Survey & Contact Form