Form S-3 - Registration Statement For Registration Of Securities By Qualification (Page 3 of 4) in pdf

Form S-3 - Registration Statement For Registration Of Securities By Qualification Page 3

Form S-3

Page 2

Total amount of securities to be offered: _______________________________________

Maximum offering price per security: _________________________________________

Number of securities to be offered in Puerto Rico: ________________________________

Maximum aggregate offering price of securities to be offered in Puerto Rico:

_________________________________________________________________________

10.

Filing fee (1/5 of 1% of maximum aggregate offering price of securities to be offered in Puerto

Rico but in any case not less than $1,000.00 or more than $2,500.00:

________________________________________________________________________

11.

Other states in which a registration statement or similar document in connection with this offering

has been or is to be filed:

________________________________________________________________________

12.

Has any adverse order, judgement, or decree been entered in connection with this offering by the

regulatory authorities in any state, or by any court, or the Securities and Exchange Commission?

______. If so, give complete details.__________________________________________

________________________________________________________________________

13.

If this offering is made by or on behalf of an issuer, state whether the issuer contemplates offering

any additional equity securities within the period of this offering or within 13 months from the

effective date of the registration statement. _____________________________ If so, give

complete details concerning the proposed offering.

________________________________________________________________________

Form S-3 - Registration Statement For Registration Of Securities By Qualification Page 3