STATE OF CALIFORNIA Department of Corporations CUSTOMER AUTHORIZATION OF DISCLOSURE OF FINANCIAL RECORDS Pursuant to Corporations Code Section 25134 and Government Code Sections 7470 and 7473, any financial institution, wherever situated, possessing financial records of the sale of _______________________________________________________________, securities qualified for sale Name or Title of Securities under the Corporate Securities Law, by ______________________________________________________________________________________ Name of Applicant seeking qualification of securities under the Corporate Securities Law is hereby authorized to disclose to the California Department of Corporations records of the sale of the above-named qualified securities whether such records relate to accounts which have been closed, accounts which are currently maintained, or accounts which are hereafter established. This authorization is effective as of the date of execution and shall remain effective until five years after the expiration or revocation of the qualification of the above-named securities, including renewals of such qualification. This authorization may not be revoked. The terms used in this authorization shall have the definitions contained in the California Right to Financial Privacy Act (Government Code Section 7460 et seq.) and the Corporate Securities Law (Corporations Code Section 25000 et seq.). The above-named applicant has duly caused this authorization to be signed on its behalf by the undersigned, thereunto duly authorized. Executed on__________________________, 20 ____, at ____________________________________ ____________________________________ Department of Corporations File Number ___________________________________ Name of Applicant By _______________________________ _______________________________ (Title) QR 500.259 (Rev. 2/01) 2002 © American LegalNet, Inc.