(Department of Corporations Use Only) Fee Paid $ ___________________ DEPARTMENT OF CORPORATIONS FILE No., if any: ______________________________ (Insert File Numbers(s) of Previous Filings Before the Department, If Any) Receipt No. __________________ FEE: $______________ (See Corporations Code Section 25608(y) and Section 25608(e). The fee is based on the current market value of the securities, or in the case of options, the underlying securities.) COMMISSIONER OF CORPORATIONS STATE OF CALIFORNIA Notice of Issuance of Securities Pursuant to Subdivision (o) of Section 25102 of the Corporations Code 1. Name of Issuer: _________________________________________________________________ 2. State of Incorporation or Organization: _______________________________________________ 3. Address of Principal Place of Business: _______________________________________________________________________________ Number and Street City State Zip Code 4. The security is issued pursuant to a: (Check One) [ ] Purchase Plan or Agreement. Name of Security: ______________________________________________________________ Number of Securities: ___________________________________________________________ Price Per Security: $____________________________________________________________ [ ] Option Plan or Agreement. Name and Number of Options: ____________________________________________________ Name and Number of the Underlying Securities: ______________________________________ _____________________________________________________________________________ Exercise Price Per Security: $_____________________________________________________ [ ] "Flexible" Purchase/Option Plan or Agreement. Name of Security/Option: ________________________________________________________ Number of Securities/Options: ____________________________________________________ Name and Number of the Underlying Securities: ______________________________________ Price Per Security: $_______________ ____________________________________________ 5. Aggregate current market value of securities sought to be sold: __ ________________________ 6. Date of Notice: ___________________ ( ) Check if Issuer has a consent to service of process on file with the Commissioner ___________________________________ Name of Issuer ______________________________________ Authorized Signature on Behalf of Issuer ______________________________________ Print Name and Title of Signatory Name, Address and Phone Number of Contact Person: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Instructions: Each issuer (other than a California corporation) filing a notice under Section 25102(o) must file a consent to service of process (Form 260.165), unless it already has a consent to service on file with the Commissioner. 25102 (o) Rev. 05-01 2002 © American LegalNet, Inc.