Form Id - Uniform Application For Access Codes To File On Edgar - U.s. Securities And Exchange Commission Page 2

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Mailing Address or Post Office Box No.
(if different from applicant’s mailing address)
City
State or Country
Zip
E-Mail Address
PART IV—ACCOUNT INFORMATION (To be completed by filers and filing agents only)
Person to receive SEC Account Information and Billing Invoices
Telephone Number
(Include Area and, if Foreign, Country Code)
Mailing Address or Post Office Box No.
(if different from applicant’s mailing address)
City
State or Country
Zip
PART V—SIGNATURE (To be completed by all applicants)
Signature
Type or Print Name
Position or Title
Date
ACKNOWLEDGEMENT
STATE OF
)
) ss.
COUNTY OF
)
I,_________________________________, a Notary Public, hereby certify that on the ___________ day of
____________, _______, personally appeared before ___________________________________ who, being by me first
duly sworn, declared that he was the person who signed the foregoing document as Incorporator and that the
statements therein contained are true.
My commission expires:
Witness my hand and official seal.
(SEAL)
______________________________Notary Public
ONCE COMPLETE, SCAN AND EMAIL THIS FORM TO HIGHLAND BUSINESS SERVICES AT
OR FAX TO (602) 375-0888.

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