Form 10-2-1 - Application For Registration By Qualification

Form 10-2-1 - Application For Registration By Qualification - Utah Page 2

Form 10-2-1

(Rev. 11/16/98)

Page 2 of 3

List the name and residential address of all directors or officers or partners of the issuer or

individuals who own of record or beneficially 10% or more of the outstanding shares of any

class of equity securities of the issuer.

Name

Address

10.

Fund Impound Agent

(Name and Address of Financial Institution)

Term of Fund Impound

(Expressed in months)

11.

The issuer's fiscal year ends

12.

Are there (or have there been) any criminal or civil complaints, or investigations by the SEC,

NASD, or other State Securities Department, covering the company or any of its officers or

directors? Yes ____ No ____. If answer is yes, explain.

13.

The applicant hereby applies for registration of securities under Section 61-1-10 of the Utah

Uniform Securities Act and in consideration thereof agrees:

Within ten working days after the expiration of effectiveness of the registration

statement, sale of the entire amount of the securities registered in the offering, or

termination of the offering, whichever occurs first, the issuer must file with the

Division, a list of persons who have purchased or subscribed to the offering, including

the residential address of each purchaser, the date of and amount of securities

purchased or subscribed to, and the consideration paid by each purchaser or

subscriber;

All amendments to the prospectus will be promptly filed with the Division, distributed

to purchasers in the offering, and made a part of any prospectus used thereafter;

The Division, market makers and security holders will be promptly notified in writing

of any change in the management, purpose, and control of the issuer, or any material

or adverse condition affecting the issuer, so long as the registration statement is

effective;

Form 10-2-1 - Application For Registration By Qualification - Utah Page 2