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

Application To Register Securities Form - 2013 Page 7

Application to register securities — continued from previous page

16. Verification by issuer:

a. List names and job titles of all officers, directors, general partners, or persons holding similar positions with the

issuer:

I declare, under penalty of perjury, that I am (title)

of the issuer and I have read and am familiar with the information in this application and with all materials or

documents to be used in connection with the offering to be made under this application. To the best of my

knowledge, information, and belief, the information contained in this application and in the offering materials is

true, correct, and complete. I have written authorization (available upon written request) from the individuals

listed above to execute this application and make this verification for and on behalf of the issuer.

Name

(print or type):

Title:

Signature:

Date:

17. Statement by broker-dealer where offering is directed to suitable persons:

The broker-dealer believes that adequate diligence and review have been applied in connection with this offering and

agrees to determine the suitability of the offering to each purchaser.

Broker-dealer:

By (name):

Title:

Signature:

Date:

Page 7 of 7

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

Application To Register Securities Form - 2013 Page 7