Sec Form 1a Regulation A Offering Statement Page 3

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electronic version of Part I will allow issuers to attach Part II and Part III for filing by means of EDGAR. All
items must be addressed, unless otherwise indicated.
* * * * * *
No changes to the information required by Part I have occurred since the last filing of this offering
statement.
ITEM 1.
Issuer Information
Exact name of issuer as specified in the issuer’s charter: _____________________________________
Jurisdiction of incorporation/organization: ________________________________________________
Year of incorporation: ______________
CIK: _____________________
Primary Standard Industrial Classification Code: ___________________________
I.R.S. Employer Identification Number: __________________________________
Total number of full-time employees: ____________________________________
Total number of part-time employees: ____________________________________
Contact Information
Address of Principal Executive Offi ces: _______________________________________________
________________________________________
Telephone: ( ) ________________
Provide the following information for the person the Securities and Exchange Commission’s staff should call in
connection with any pre-qualification review of the offering statement:
Name: ____________________________________________________
Address: __________________________________________________
Telephone: ( )____________________________
Provide up to two e-mail addresses to which the Securities and Exchange Commission’s staff may send any
comment letters relating to the offering statement. After qualification of the offering statement, such e-mail ad-
dresses are not required to remain active: _______________________________________________________
________________________________________________________________________________________
3

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