Notice Of Sale Of Securities Pursuant To Accredited Investor Exemption Form (Page 4 of 4) in pdf

Notice Of Sale Of Securities Pursuant To Accredited Investor Exemption Form Page 4

7. Submitted herewith as part of this notice are the following:

(a)

A copy of the general announcement (if one made regarding the proposed

offering);

(b)

Consent to service of process; and

(c)

A non-refundable filing fee of five hundred dollars ($500).

Execution and Certification

By filing this Notice of Transaction, the Issuer of these securities hereby represents that:

The undersigned represents that the Issuer is familiar with the conditions that must be

satisfied to be entitled to the Accredited Investor Exemption of the state in which this notice is

filed and understands that the Issuer claiming the availability of this exemption has the burden of

establishing that these conditions have been satisfied; and.

On the basis of representations, certifications or other evidence received from purchasers

of securities in this offering, the Issuer believes that all such purchasers are “accredited

investors” as defined in T.C.A. § 48-2-102(16).

The issuer has read this notification and knows the contents to be true and has duly caused this

notice to be signed on its behalf by the undersigned duly authorized person.

Issuer (Print or Type)

Signature

Name (Print or Type)

Title (Print or Type)

Date

IN-1460

RDA 959

Page 4 of 4

Notice Of Sale Of Securities Pursuant To Accredited Investor Exemption Form Page 4