Notice of Exempt Securities Transactions Given at the option of the issuer/agent 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 This form is provided for those who want to notify the division of an offering to be offered under one of the exemptions that are self-executing. You will receive an order of effectiveness just as you would any other exemption and that tells you the request has been reviewed and found to comply with the appropriate statute. Filing is not required, however, if you elect to file a notice it must be accompanied by the fee required by 3 AAC 08.920(6). 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. PLEASE SPECIFICALLY NOTE THE EXEMPTION YOU CLAIM UNDER æ 5. Date sales are to commence: 08-116 (rev. 8/01) American LegalNet, Inc. www.USCourtForms.com 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. I understand I am not required to file this notice, but have elected to do so anyway. I accept all responsibility that goes with making this filing. (Note AS 45.55.160) 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): 08-116 (rev. 8/01) For Office Use only American LegalNet, Inc. www.USCourtForms.com