Form Sc-610-009 - Notification Of Claim Exemption Page 2
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2By filing this Notification of Claim of Exemption in the state of Washington pursuant to WAC 460-44A-503(1)(a)(i)(D), the
issuer of these securities hereby represents that::
(1) The issuer shall at the time of any offers and sales be a person resident and doing business within
Washington, and that all offers to sell, offers for sale, and sales shall be made within this state;
(2) Offers, offers to sell, offers for sale and sales of these securities shall be made only to persons
resident
within the state of Washington; and
(3)The issuer has reviewed and shall meet the requirements for exemption from registration pursuant to
Securities and Exchange Commission Rule 147, and shall disclose in writing the limitations on resales
and implement precautions against interstate offers and sales as provided in the rule, including placing a
legend on the certificate or other document evidencing the security stating that the securities have not
been registered under the Act and setting forth the limitations on resale as stated below, and obtaining a
written representation from each purchaser as to his residence.
THESE SECURITIES HAVE NOT BEEN REGISTERED WITH THE SECURITIES AND EXCHANGE COMMISSION
UNDER THE SECURITIES ACT OF 1933 (“ THE ACT” ), BUT ARE BEING SOLD IN RELIANCE UPON THE
EXEMPTION FROM REGISTRATION PROVIDED IN SECTION 3(A)(11) OF THE ACT AND RULE 147
PROMULGATED THEREUNDER. ACCORDINGLY, RESALES AND TRANSFERS OF THESE SECURITIES ARE
STRICTLY LIMITED TO RESIDENTS OF THE STATE OF WASHINGTON FOR A PERIOD OF AT LEAST NINE
MONTHS FROM THE DATE OF THE LAST SALE OF THE OFFERING BY THE ISSUER OF THE SECURITIES IN
WHICH THE SECURITIES ARE DEEMED TO BE A PART.
DO NOT SEND OFFERING MATERIALS OR PROSPECTUS UNLESS
SPECIFICALLY REQUESTED BY THE SECURITIES DIVISION
The undersigned officer or person acting in a similar capacity has duly caused this notification to be filed on
behalf of the issuer and has read this notification and knows the contents hereof and the statements therein to be
true.
ISSUER _______________________________ DATE _____________________________
SIGNATURE ______________________________________________________________
_________________________________________________________________________
Type Name and Title
Subscribed and sworn to before me this
_____________ day of ____________ 19 _________
S
_____________________________________________
E
A
_____________________________________________
L
Residing at __________________________________
ATTENTION: Intentional misstatements or omissions of facts
constitute criminal violations. (See RCW 21.20.400)
SC-610-009 (R/8/93)M Page 2 of 2
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