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Form 6(A)(4) - Registration By A Corporation Of A Proposed Sale Of Additional Securities To Existing Security Holders Pursuant Page 4

SIGNATURE

Issuer _______________________________

By _______________________________

(Title)

VERIFICATION

(Verification by One Person is Sufficient)

County of

State of

The undersigned,

being first duly

sworn, deposes and says:

That he has executed the foregoing for, and on behalf of, the applicant named therein; that he is

of such

applicant and is fully authorized to execute and file such application; that he is familiar with such application and the facts underlying such

application; and that to the best of his knowledge, information and belief, the statements made in such application are true and the

documents submitted herewith are true copies of the original thereof.

Signature of Person Sworn

Office Held

Month, Day and Year

Subscribed and sworn to before me

Signature of Notary Public

A Certificate of Acknowledgment will be mailed at effectiveness in seven business days pursuant to R.C. Section 1707.08 if the registration

by description is not suspended or refused pursuant to R.C. Sections 1707.13 or 1707.131. No form can be returned for correction, nor

can a refund be made of filing fees.

Submit completed registration together with $50.00 fee to Division of Securities, 77 South High Street, Floor 22, Columbus, Ohio 43215-

6131.

Form 6(A)(4) - Registration By A Corporation Of A Proposed Sale Of Additional Securities To Existing Security Holders Pursuant Page 4