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Form Ofr-S-1-91 - Application For Registration Of Securities - Florida Office Of Financial Regulation Page 4

(f) File with the Office of Financial Regulation:

(i)

All amendments to the letter of notification pursuant to Regulation A, Schedule D

pursuant to Regulation B, or other appropriate registration statement or offering

circular. Amended information or material within such exhibits shall be designated

by underlining; and

(ii)

The final prospectus, offering circular, or other appropriate registration statement

or form, and any subsequent amendments or supplements thereto.

(g) Notify the Office of Financial Regulation within two (2) business days (i) upon receipt of

any stop order, denial, order to show cause, suspension or revocation order, injunction or

restraining order, or similar order entered or issued by any other state or other regulatory

authority or by any court, concerning the securities covered by this application or other

securities of the issued currently being offered to the public, and (ii) upon any request by

the issuer or application to any other state or regulatory authority for permission to

withdraw any application to register the securities covered by this application.

(h) Furnish promptly all additional information and documents requested by the Office of

Financial Regulation which are necessary to ascertain whether the securities shall be

registered under Chapter 517, Florida Statutes.

Signed this _____ day of _________________, ______

_____________________________________________

NAME OF NOTIFIER

By: _________________________________________

Signature and Official Capacity or

Person signing for Applicant

STATE OF _________________________)

) ss.

COUNTY OF _______________________)

_________________________, being duly sworn, deposes and says that he signed the foregoing notification

as _______________________ (Official Capacity) of the above-named applicant having full authority to sign

such application and has examined the exhibits required to be submitted with such application, which exhibits

by reference and identification are made a part of such application; and that the information contained herein

is true; that he has carefully examined all statements and answers in the within application and exhibits

submitted therewith and made a part thereof, and that each of the statements, answers and representations

made are true, and that no material fact in answer to the several questions has been omitted.

OFR-S-1-91, Application for Registration of Securities, Effective 11/22/10, Incorporated by Reference in Rule 69W-

301.0002, F.A.C.

Form Ofr-S-1-91 - Application For Registration Of Securities - Florida Office Of Financial Regulation Page 4