Form D-1 - Notice Of Sale Of Securities Pursuant To The Delaware Limited Offering Exemption Form - State Of Delaware Page 3

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11. State the name, home and business address, occupations, and dollar amount paid by each
purchaser who is a Delaware resident.
NAME
HOME AND BUSINESS
OCCUPATION
DOLLAR AMOUNT
ADDRESS
____________________________________________
______________________________________________
_____________________________________________
12. If any purchase utilized an Offeree Representative (or Purchaser Representative) state the name of
the Representative, his or her business address and the offeree or purchaser represented.
OFFEREE OR PURCHASER
BUSINESS
REPRESENTATIVE
ADDRESS
PURCHASER
13. Please provide on a separate sheet the information required in Section C of SEC Form D regarding
Offering Price, Number of Investors, Expenses and Use of Proceeds.
3

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