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TO THE COMMISSIONER OF CORPORTIONS OF

THE STATE OF CALIFORNIA:

STATEMENT OF TRANSFEREE TO ACCOMPANY

APPLICATION FOR CONSENT TO TRANSFER SECURITIES

SUBJECT TO LEGEND OR ESCROW CONDITION

(If securities are to be received in pledge, so state.)

The undersigned intends to purchase* _________________________ shares or units

(number)

of ________________________________________________________________________

(Description of security, e.g., $10 common, Class A common)

issued by __________________________________________________________________

(Name of Issuer)

from ________________________________________ and makes the following statements:

I have received from the issuer and/or the transferor a recent financial statement of the

issuer and such additional information with respect to the issuer as I have deemed

necessary to make an independent evaluation of the business prospects of the issuer

and the fairness of the investment: (If answered in the negative, explain fully.)

Yes

I am a director and/or an office of issuer ………………………………

Yes

(a) I will actively participate in the operation of issuer’s business and devote my full time

or a substantial portion of my time thereto, with an opportunity to be fully aware of all of

issuer’s affairs……………………………………………………………..

Yes

(b) I will be compensated for such services……………………………

Yes

Are the securities being purchased promotional shares subject to waivers of assets and

dividend? (See Sections 260.141 and 260.141.1 of the rules.)…….

Yes

If the issuer is not a partnership and all parts of questions 2 and 3 above are answered

in the negative, attach a separate signed statement elaborating on the items shown

below:

(a) The length of time officers and directors of issuer have been known, and the nature

of prior business dealings with any officer or director of issuer or with the issuer.

(b) Any prior investment experience in a business of similar size and nature.

either the net worth or the annual income of the transferee.

(d) Whether the transferee has received advice from any attorney, accountant or other

professional adviser independent of the issuer.

(e) How transferee became aware of proposed investment.

If the issuer is a partnership, complete the following:

(a) My annual income is in excess of $____________________________.

(b) My net worth (exclusive of my home, its furnishings and my automobiles) is in

excess of $________________________.

260.151(b) (Register 2002, No. 39)

Form 260.151(B) - Statement Of Transferee To Accompany Application For Consent To Transfer Securities