FORM RQ Colorado File No.: RQ________________ Colorado Division of Securities 1560 Broadway Street, Suite 900 Denver, CO 80202 APPLICATION FOR REGISTRATION BY QUALIFICATION Pursuant to the requirements of section 11-51-304, C.R.S., application is made for registration of the described securities and the following information is submitted: 1. 2. _____________________________ ____________________________________ _____________________________ ____________________________________ _____________________________ 3. NAME AND ADDRESS OF ISSUER: TITLE OR DESCRIPTION OF SECURITY: ____________________________________ AMOUNT TO BE REGISTERED: Offering Price Amount of Securities $_________________ ____________________ Total Amount $____________________ 4 Is this an initial Colorado registration or an amendment to increase the size of a previously registered Colorado offering? ________________________________________________________________________ 5. NAME AND ADDRESS OF PRINCIPAL BROKER-DEALER (IF ANY): __________________________________________ __________________________________________ __________________________________________ 6. Will these securities be sold by an individual acting as a sales representative for the issuer? _____YES _____ NO 7. NAME, ADDRESS AND TELEPHONE NUMBER OF ATTORNEY, AGENT OR CORRESPONDENT: __________________________________________ __________________________________________ __________________________________________ 8. Attach Appointment and Consent to Service of Process (Forms U-2 & U-2a); or, if such forms have previously been filed with this office, state the date filed and the documents which they accompanied. ________________________________________________________ 9. FILING FEE: $_______________ (payable to “Colorado State Treasurer”) ________________________________________________ Signature of Applicant ________________________________________________ Type the Name and Title of Applicant (Rev. 7/2006)