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Registration By Notification Non-Issuer Distribution Form - Commonwealth Of Virginia

S.A.5

(Rev. 11/96)

COMMONWEALTH OF VIRGINIA

STATE CORPORATION COMMISSION

DIVISION OF SECURITIES AND RETAIL FRANCHISING

REGISTRATION BY NOTIFICATION

Non-Issuer Distribution

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.)

__________________________________________________________________________

Are the offer and sale of the securities hereby directly or indirectly for the benefit of the

issuer?

__________________________________________________________________________

Have securities of the same class as the security being registered previously been registered

in Virginia?

__________________________________________________________________________

If so, give the date of registration and the name of the person by whom they were registered.

__________________________________________________________________________

Were the securities being registered originally issued pursuant to an exemption under § 13.1-

514? ______________ If so, state which exemption.

__________________________________________________________________________

The registrant, after investigation, believes that the facts herein stated are true.

_____________________________________________

By __________________________________________

Address ______________________________________

Date:______________________

_____________________________________________

Registration By Notification Non-Issuer Distribution Form - Commonwealth Of Virginia