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Registration By Notification

S.A. 4

(Rev. 11/96)

COMMONWEALTH OF VIRGINIA

STATE CORPORATION COMMISSION

DIVISION OF SECURITIES AND RETAIL FRANCHISING

_____________

REGISTRATION BY NOTIFICATION

Original Issue

Name and address of issuer ________________________________________________________

______________________________________________________________________________

Description of the securities and total amount to be offered ______________________________

______________________________________________________________________________

Number of securities to be offered in Virginia _________________________________________

Maximum price per security _______________________________________________________

Fee (1/20 of 1% of the maximum offering price of the securities to be offered in this state; but

such fee shall not be less than $100 nor more than $250.) _______________________________

Date and place of incorporation or organization

______________________________________________________________________________

How long has the issuer (including any predecessor by merger, consolidation or acquisition of

assets) been in continuous operation? ________________________________________________

Has there been any default by the issuer within its past three fiscal years in payment of principal,

interest or dividends on any of its debt obligations or preferred stock? ______________________

If the securities being registered include common stock and are registered under § 13.1-508 A 1

(A), answer the following:

Value of the issuer’s assets after deduction of depreciation and other reserves; and the

basis of such value (cost, etc.) _______________________________________________

What is the net worth of the issuer? __________________________________________

10.

If the securities being registered include common stock and are registered under § 13.1-508 A 1

(B), answer the following:

Net earnings of issuer applicable to all common stock during each of the past three fiscal

years:

(1)

____________________

(2)

____________________

(3)

____________________

Average

_________________

Registration By Notification