Notice of Exempt Securities Transactions Under AS 45.55.900(b)(5)(B) (To be filed along with the fee required at 3 AAC 08.910(6)) Please fill out this form and submit to: Administrator of Securities Alaska Division of Banking, Securities, and Corporations P.O. Box 110807 Juneau, AK 99811-0807 (907) 465-2521 1. Name, Address, and Telephone number of contact person filing this notice: Full Name Address Phone Fax The person signing this form must show name & address above. If different from the contact person, show information on signer as well. 2. Name, Address, and Telephone number of Issuer Entity requesting exemption: Name of Entity Address Phone 3. q Yes q No Formed, or to be formed, as an Alaska domestic (Corporation, LP, LLP, or LLC) under Alaska Statutes Title 10 or Title 32. 4. Please provide a brief description of terms of the offering (including security and price). If more space is needed, use page two or include attachments. 5. Date sales are to commence: (may not be sooner than 2 days after the filing date of the exemption notice or as determined by the administrator) 6. Describe any special circumstances you ask the administrator to consider. If more space is needed, use page two or include attachments. Waiver requests must include full disclosure to the administrator of the facts and relevant material factors relating to the request. 08-107 (rev. 8/01) American LegalNet, Inc. www.USCourtForms.com By filing this document, I affirm the following: Sales will be made to no more than 25 persons in this state other than those designated at AS45.55.900(b)(4) during the 12 consecutive-month-period-of-effectiveness regardless of whether the seller or any of the buyers is then present in this state. It is understood that “in this state” has the same meaning as that phrase is used at AS 45.55.980(c) (See Attachment A below, do not return to agency); Sales will be made solely in this state which is understood to mean that the issuer meets the criteria of 17 C.F.R. 230.147(c) (See Attachment B below, do not return to agency); Before a sale, the prospective buyer will be furnished access to information sufficient to make an informed investment decision. That information must satisfy the requirement of AS 45.55.900(b)(5)(B)(ii), and will be furnished to the administrator at the administrator’s request; Commissions or other remuneration meet the requirements of AS 45.55 and will be made only to persons registered under AS 45.55.040; A legend will be placed on the certificate or other document evidencing ownership of the security, stating that the security is not registered under The Alaska Securities Act, AS 45.55, and cannot be resold without registration under AS 45.55 or exemption from such registration; A signed agreement will be obtained from each buyer at the time of sale or before that the buyer is buying for investment purposes and that the securities will not be resold without registration or exemption under AS 45.55; Offers will be made without public solicitation or advertisement; This notice filing is the notice required under AS 45.55.900(b)(5)(B)(vii), and must be in the hands of the administrator, together with the fee described at 3 AAC 08.910(6), at least two days before any sales are made, unless the two-day waiting period is waived by the administrator in the order of effectiveness; and The offering will comply with the limitations of 3 AAC 08.910(3)(E). Under AS 45.55.160, It is UNLAWFUL to file with the Administrator of Securities any document that would make, or cause to be made, an untrue or misleading statement of material fact or omit to state a material fact necessary so as to make the statement made not misleading. Signature of attorney or principal ( please describe which) Title Date E-mail address (to receive notice of effectiveness): Additional space (Please refer to ¶ number being amplified): 08-107 (rev. 8/01) For Office Use only American LegalNet, Inc. www.USCourtForms.com