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Registration By Notification Non-Issuer Distribution "Secondary Trading" Form - Commonwealth Of Virginia

S.A. 6 (1989)

COMMONWEALTH OF VIRGINIA

STATE CORPORATION COMMISSION

DIVISION OF SECURITIES AND RETAIL FRANCHISING

REGISTRATION BY NOTIFICATION

Pursuant to 21 VAC 5-30-50

Non-Issuer Distribution

“Secondary Trading”

Name and address of issuer: _______________________________________________________

______________________________________________________________________________

Name and address of registrant: ____________________________________________________

______________________________________________________________________________

Name, address and telephone number of correspondent to whom notice and communications

regarding this application may be sent:_______________________________________________

______________________________________________________________________________

Description of the securities to be registered: __________________________________________

______________________________________________________________________________

Offering price

Number

Amount

____________

_________

_______________

Fee (1/20 of 1% of the “Amount” in 5 above; minimum fee $100; maximum fee $250):

$_________________________

Are the above described securities to be offered and sold directly or indirectly for the benefit of

the issuer? _______ YES

_______ NO

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

pursuant to the Virginia Securities Act, the Securities Act of 1933 or the Securities Exchange Act

of 1934? _______________________________________________________________________

If so, identify the Act and 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 making reasonable inquiry, believes that the facts herein stated are true.

Registrant :

By :

Title :

Date: __________________________

Registration By Notification Non-Issuer Distribution "Secondary Trading" Form - Commonwealth Of Virginia