Form U-1 - Uniform Application To Register Securities - Washington State Department Of Financial Institutions Page 3

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(e) Furnish promptly all such additional information and documents in respect to the issuer or the securities
covered by this application as may be requested by the above named state authority prior to registration or
acceptance for filing.
Date:
(Name of Applicant)
By
(Name and Title)
State of
}
SS
County of
The undersigned,
, being first duly sworn,
deposes and says:
That he has executed the foregoing application 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 that to the best of his knowledge, information and
belief the statements made in such application are true and the documents submitted therewith are true copies
of the originals thereof.
(Name)
Subscribed and sworn to before me this
day of
,
NOTARY PUBLIC
In and for the County of
State of
My Commission Expires:
(Notarial Seal)

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