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Form Rq - Application For Registration Of Securities By Qualification - Alabama Office Of The Securities Commission Page 7

(Seal)

Signature, and official capacity of person

Signing for applicant

STATE OF ________________________

SS.

COUNTY OF ______________________

__________________________________________ being duly sworn, deposes and says that he

signed the foregoing application as _________________________________________________

State Official Capacity

Of the above named applicant, having full authority to sign such application and has examined

the exhibits required to be submitted with such application, which exhibits by reference and

identification are made a part of such application, and that the information contained therein is

true; that he has carefully examined all statements and answers in the within application and

exhibits submitted therewith and made a part there thereof, and that each of the statements,

answers and representations made are true, and that no material fact in answer to the several

questions has been omitted.

Signature

Subscribed and sworn before me this ________ day of ___________ 20________.

(Notarial Seal)

My commission expires:

Form Rq - Application For Registration Of Securities By Qualification - Alabama Office Of The Securities Commission Page 7