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

Form 10-2-1 - Application For Registration By Qualification - Utah Page 3

Form 10-2-1

(Rev. 11/16/98)

Page 3 of 3

Financial statements will be submitted to the Division in accordance with Section

R164-10-2(H) of the Utah Administrative Code.

14.

The applicant hereby affirms that no material contract, understanding or agreement exists

which is not reflected in the registration statement.

State of

)

) ss.

County of

)

, the undersigned,

being first duly sworn, deposes and says that he or she has executed the foregoing application for and

on behalf of the applicant, that he or she is the

of such applicant and is fully authorized to execute and file such application; that he or she is familiar

with such application, and that to the best of his or her knowledge, information and belief, the

statements made in such application are true and the documents submitted herewith are true copies

of the original thereof.

Signature

Subscribed and sworn to before me this

day of

Notary Public

The undersigned directors, officers, partner or partners of the issuer named herein do hereby

affirm that they have read this registration statement and all exhibits thereto, and that the contents

thereof are true to the best of their knowledge and belief; and further that

is hereby authorized to execute this registration statement on behalf of the issuer, and continuing

authority is hereby delegated to him or her to file any amendments, supplementary or periodic

information thereto as may be applicable or required, pursuant to the Utah Uniform Securities Act,

and rules promulgated thereunder.

Signature

Title

Form 10-2-1 - Application For Registration By Qualification - Utah Page 3