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Street Address 1 1330 Post Oak Boulevard
Street Address 2 Suite 1825
City Houston
State/Province/Country TEXAS
ZIP/PostalCode 77056
Relationship: [x] Executive Officer [] Director [] Promoter
Clarification of Response (if Necessary):
Last Name Gustin
First Name Charlie
Middle Name
Street Address 1 1330 Post Oak Boulevard
Street Address 2 Suite 1825
City Houston
State/Province/Country TEXAS
ZIP/PostalCode 77056
Relationship: [] Executive Officer [x] Director [] Promoter
Clarification of Response (if Necessary):
4. Industry Group
[] Agriculture
Banking & Financial Services
[] Commercial Banking
[] Insurance
[] Investing
[] Investment Banking
[] Pooled Investment Fund
Is the issuer registered as an investment company under the Investment Company Act of 1940?
Health Care
[] Biotechnology
[] Health Insurance
[] Hospitals & Physicians
[] Pharmaceuticals
[] Other Health Care
[] Manufacturing
Real Estate
[] Commercial
[] Retailing
[] Restaurants
Technology
[] Computers
[] Telecommunications
[] Other Technology
Travel
[] Airlines & Airports
[] Lodging & Conventions
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https://www.sec.gov/Archives/edgar/data/1646230/000164623018000003/xslFormDX01/primary_doc.xml
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11/8/23, 12:26 PM
SEC FORM D
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Does the Issuer intend this offering to last more than one year? [] Yes [x] No
9. Type(s) of Securities Offered (select all that apply)
[] Equity
[x] Debt
[x] Option, Warrant or Other Right to Acquire Another Security
[x] Security to be Acquired Upon Exercise of Option, Warrant or Other Right to Acquire Security
[] Pooled Investment Fund Interests
[] Tenant-in-Common Securities
[] Mineral Property Securities
[] Other (describe)
10. Business Combination Transaction
Is this offering being made in connection with a business combination transaction, such as a merger, acquisition or exchange offer? [] Yes [x] No
Clarification of Response (if Necessary):
11. Minimum Investment
Minimum investment accepted from any outside investor $0 USD
12. Sales Compensation
Recipient
Recipient CRD Number [x] None
(Associated) Broker or Dealer [x] None
(Associated) Broker or Dealer CRD Number [x] None
Street Address 1
Street Address 2
City
State/Province/Country
ZIP/Postal Code
State(s) of Solicitation (select all that apply) Check “All States” or check individual States [] All States [] Foreign/non-US
13. Offering and Sales Amounts
Total Offering Amount $1,500,000 USD or [] Indefinite
Total Amount Sold $1,000,000 USD
Total Remaining to be Sold $500,000 USD or [] Indefinite
Clarification of Response (if Necessary):
14. Investors
[] Select if securities in the offering have been or may be sold to persons who do not qualify as accredited investors, and enter the number of such non-accredited investors who already have invested in the offering. ___
Regardless of whether securities in the offering have been or may be sold to persons who do not qualify as accredited investors, enter the total number of investors who already have invested in the offering: 1
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