Application To Register Securities Form - 2013 (Page 6 of 7) in pdf

Application to register securities — continued from previous page

12. Aggregation: Have any securities of the entity that will issue the securities in this registration been sold within the 12

months preceding the effective date of this registration?

Yes

What was the aggregate price? $

See OAR 441-065-0700(3) for definition of aggregate offering price.

13. Actions against issuer and affiliated parties (issuer’s predecessors, affiliates, officers, directors, general partners,

promoters, or beneficial owners of more than 10 percent of any class of issuer’s equity securities):

Check and provide details if any of these persons listed:

Filed a registration statement that is the subject of an effective stop order entered by any state or federal agency

within five years prior to the registration of the offering.

Was convicted, within five years prior to this registration, of any felony or misdemeanor in connection with the

purchase or sale of any security or involving the making of a false filing with a state or federal agency.

Was convicted, within five years prior to this registration, of any felony involving fraud or deceit including, but

not limited to, forgery, embezzlement, obtaining money under false pretenses, larceny, or conspiracy to defraud.

Was subject to any state administrative order or judgment or any federal administrative order or judgment, within

five years prior to the filing of the registration, that involves state or federal securities law as the grounds for the

order of judgment.

Was the subject of any revocation, cancellation, withdrawal, suspension, or other adverse order or directive of the

National Association of Securities Dealers or any securities exchange.

Is now the subject of any complaint, investigation, or proceeding related to the five preceding items.

14. Application for waivers: Waiver is sought from the provisions of

Issuer must attach the documentation required for the waiver or the request will not be considered.

15. Undertakings and representations: The issuer hereby applies for registration of these securities and agrees to do the

following, as long as the registration remains in effect:

a. Advise the director of DCBS of any changes prior to registration in any of the information filed with this

application and to file necessary amendments promptly.

b. Notify the director within two business days of receipt of any stop order, denial, order to show cause, suspension,

or revocation order, injunction or restraining order, or similar order entered or issued by any state or other

regulatory authority or by any court concerning the securities covered by this statement or any other securities of

the issuer or applicant.

c. Furnish any additional information or documents requested by the director before or after registration.

d. Advise the director where and when rescission is sought and file and obtain an amendment or registration.

e. Keep and maintain all records pertaining to this offering for at least three years from the date of registration.

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440-2013 (6/06/COM/WEB)

Application To Register Securities Form - 2013 Page 6