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Street Address 1 1330 Post Oak Boulevard
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Street Address 2 Suite 1825
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City Houston
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State/Province/Country TEXAS
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ZIP/PostalCode 77056
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Relationship: [x] Executive Officer [] Director [] Promoter
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Clarification of Response (if Necessary):
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Last Name Gustin
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First Name Charlie
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Middle Name
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Street Address 1 1330 Post Oak Boulevard
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Street Address 2 Suite 1825
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City Houston
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State/Province/Country TEXAS
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ZIP/PostalCode 77056
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Relationship: [] Executive Officer [x] Director [] Promoter
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Clarification of Response (if Necessary):
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4. Industry Group
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[] Agriculture
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Banking & Financial Services
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[] Commercial Banking
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[] Insurance
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[] Investing
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[] Investment Banking
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[] Pooled Investment Fund
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Is the issuer registered as an investment company under the Investment Company Act of 1940?
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Health Care
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[] Biotechnology
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[] Health Insurance
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[] Hospitals & Physicians
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[] Pharmaceuticals
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[] Other Health Care
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[] Manufacturing
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Real Estate
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[] Commercial
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[] Retailing
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[] Restaurants
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Technology
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[] Computers
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[] Telecommunications
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[] Other Technology
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Travel
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[] Airlines & Airports
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[] Lodging & Conventions
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https://www.sec.gov/Archives/edgar/data/1646230/000164623018000003/xslFormDX01/primary_doc.xml
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2/5
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--------------------------------------------------- Unstructured Plain Text Format 1
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11/8/23, 12:26 PM
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SEC FORM D
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Does the Issuer intend this offering to last more than one year? [] Yes [x] No
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9. Type(s) of Securities Offered (select all that apply)
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[] Equity
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[x] Debt
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[x] Option, Warrant or Other Right to Acquire Another Security
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[x] Security to be Acquired Upon Exercise of Option, Warrant or Other Right to Acquire Security
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[] Pooled Investment Fund Interests
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[] Tenant-in-Common Securities
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[] Mineral Property Securities
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[] Other (describe)
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10. Business Combination Transaction
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Is this offering being made in connection with a business combination transaction, such as a merger, acquisition or exchange offer? [] Yes [x] No
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Clarification of Response (if Necessary):
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11. Minimum Investment
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Minimum investment accepted from any outside investor $0 USD
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12. Sales Compensation
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Recipient
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Recipient CRD Number [x] None
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(Associated) Broker or Dealer [x] None
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(Associated) Broker or Dealer CRD Number [x] None
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Street Address 1
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Street Address 2
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City
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State/Province/Country
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ZIP/Postal Code
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State(s) of Solicitation (select all that apply) Check “All States” or check individual States [] All States [] Foreign/non-US
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13. Offering and Sales Amounts
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Total Offering Amount $1,500,000 USD or [] Indefinite
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Total Amount Sold $1,000,000 USD
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Total Remaining to be Sold $500,000 USD or [] Indefinite
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Clarification of Response (if Necessary):
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14. Investors
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[] 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. ___
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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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--------------------------------------------------- Unstructured Form End
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