Form 10-2-1b - Certification Form - Department Of Commerce Division Of Securities - State Of Utah
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1(Rev.11/16/98)
STATE OF UTAH
DEPARTMENT OF COMMERCE
DIVISION OF SECURITIES
FORM 10-2-1B
Certification
STATE OF
)
) ss.
COUNTY OF
)
The undersigned,
an officer, director, promoter, holder of 10%
of the outstanding stock, underwriter or sales agent, or attorney for
(the "Company"), being first duly sworn, does hereby certify under oath that the information in the
Company's registration statement submitted to the Utah Department of Commerce, Division of
Securities is true, accurate and complete to the best of his or her knowledge and that he or she has
been diligent in confirming there are no promoters, material transactions, payments to related parties,
stock distribution arrangements or material compensation arrangements which are not disclosed in
the registration statement.
Dated
Signature
Affiliation with Company
Subscribed and sworn to before me this
day of
, 19
.
Notary Public
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