Form 8-Nr-2 - Rescission Notice And Notification Form

SECURITIES AND BUSINESS REGULATION

237 Coliseum Drive

Macon, Georgia 31217-3858

(478) 207-2440

BRIAN P. KEMP

Commissioner of Securities

RESCISSION NOTICE AND NOTIFICATION FORM

Georgia Uniform Securities Act of 2008

O.C.G.A. § 10-5-23

INSERT THE FOLLOWING NOTICE OF RESCISSION on the inside front cover page of the prospectus in the case

of a printed prospectus or on the second page of the prospectus in the case of a prospectus reproduced by any other means,

in boldfaced print or CAPITAL type:

ANY PERSON WHO PURCHASES THE SECURITIES OFFERED HEREBY SHALL HAVE

THE UNQUALIFIED AND UNWAIVABLE RIGHT TO RESCIND SUCH PURCHASE

WITHIN THREE (3) BUSINESS DAYS OF THE EXECUTION OF A WRITTEN AGREEMENT TO PURCHASE

ANY SECURITIES OFFERED HEREBY, THE DELIVERY OF A CONFIRMATION OF SALE, OR THE PAYMENT

FOR ANY SECURITIES OFFERED HEREBY, WHICHEVER SHALL OCCUR FIRST.

RESCISSION MAY BE ACCOMPLISHED BY COMPLETING AND

MAILING THE FORM PROVIDED ON PAGE ______ OF THIS PROSPECTUS.

INSERT THE FOLLOWING NOTIFICATION OF RESCISSION on the inside back cover page in the case of a

printed prospectus or the final page in the case of a prospectus reproduced by any other means, to provide a means of

exercising the right of rescission provided in section 10-5-23 of the Georgia Uniform Securities Act of 2008. Separate

forms are required, addressed to both the issuer and the Commissioner of Securities.

NOTICE OF RESCISSION

TO: COMMISSIONER OF SECURITIES

OFFICE OF THE SECRETARY OF STATE

237 COLISEUM DRIVE

MACON, GEORGIA 31217

I hereby exercise my right to rescind my purchase of ____________shares of the________________________________.

__________________________________________

(Name of Issuer/Company)

This rescission is made within three (3) business days of the earliest of my execution of a written agreement to purchase

said shares, the delivery of a confirmation of sale of said shares to me or the payment for such shares, the delivery of a

confirmation of sale of said shares to me or the payment for such shares. I understand that the effective date of the

rescission shall be the date of delivery of this Notice or the depositing of same, properly addressed with adequate postage

thereon, in the United States Mail.

DATED, this _______________day of __________________________, 20___

SIGNATURE ____________________________________________________________________________

NAME ____________________________________________________________________________

ADDRESS _________________________________________________________________________

CITY ______________________________________ STATE ____________ ZIP CODE ___________

Form 8-NR-2

Rev. 2/2011

Form 8-Nr-2 - Rescission Notice And Notification Form - 2011