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Customer Authorization Of Disclosure Of Financial Records Form - California Department Of Corporations

STATE OF CALIFORNIA

Department of Corporations

CUSTOMER AUTHORIZATION OF

DISCLOSURE OF FINANCIAL RECORDS

Pursuant to Corporations Code Section 25134 and Government Code Sections 7470 and 7473, any financial

institution, wherever situated, possessing financial records of the sale of

_______________________________________________________________, securities qualified for sale

Name or Title of Securities

under the Corporate Securities Law, by

______________________________________________________________________________________

Name of Applicant seeking qualification of securities

under the Corporate Securities Law

is hereby authorized to disclose to the California Department of Corporations records of the sale of the

above-named qualified securities whether such records relate to accounts which have been closed, accounts

which are currently maintained, or accounts which are hereafter established.

This authorization is effective as of the date of execution and shall remain effective until five years after the

expiration or revocation of the qualification of the above-named securities, including renewals of such

qualification.

This authorization may not be revoked.

The terms used in this authorization shall have the definitions contained in the California Right to Financial

Privacy Act (Government Code Section 7460 et seq.) and the Corporate Securities Law (Corporations Code

Section 25000 et seq.).

The above-named applicant has duly caused this authorization to be signed on its behalf by the

undersigned, thereunto duly authorized.

Executed on__________________________, 20 ____, at

____________________________________

___________________________________

Department of Corporations

Name of Applicant

File Number

By _______________________________

_______________________________

(Title)

QR 500.259 (Rev. 2/01)

Customer Authorization Of Disclosure Of Financial Records Form - California Department Of Corporations