Subscribed and sworn to before me
this ______ day of _________________, _____
______________________________________________
NOTARY PUBLIC
My Commission expires: __________________
____ Corporation does not have a seal.
(Notarial Seal)
OFR-S-1-91, Application for Registration of Securities, Effective 11/22/10, Incorporated by Reference in Rule 69W-
301.0002, F.A.C.
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