Investor Questionnaire

THIS INVESTOR SUITABILITY QUESTIONNAIRE DOES NOT CONSTITUTE AN OFFER TO SELL OR THE SOLICITATION OF AN OFFER TO BUY ANY SECURITIES OF MICROTRANSPONDER, INC.

This is the first step in the process of an investment in MicroTransponder and must be completed in order to receive additional investment information.

Please check your email immediately following the submission of your information, you will need to reply to that email in order to receive information.

1. What is your Full Legal Name? *This question is required.

2. What Email address would you prefer that we use to send you additional information? *This question is required. This question requires a valid email address.