Midwest Regional Review Application When complete, save as a new file, print, sign, and submit the hard copy with the other required documents. 1. Name of Issuer: _____________________________________________________________ Fax Number:_______________ E-Mail Address:__________________________________ 2. The issuer ("applicant") is filing for Coordinated Midwest Regional Review in the following states indicated by check or “X” (at least two must be indicated): _____ Illinois _____ Indiana _____ Iowa* _____ Kansas _____ Michigan _____ Minnesota _____ Missouri _____ Nebraska _____ North Dakota _____ South Dakota _____ Wisconsin *Offering may not exceed $1 million 3. The applicant shall send to each state checked above, a copy of this Application, the required fees for registration in the state and all required exhibits (see links for “Participating States” and “Required Exhibits to be Filed with Application” under “Site Contents” on the Internet home page of MRRP at http://www.securities.state.ks.us/mrrp/mrrpmain.html ). These filings shall be made simultaneously in each state as checked in Item 2 above. The documents filed in each state shall be identical. (Note: Subsequent to the initial filing for Midwest Regional Review, the applicant may file a new application in at least two of the remaining participating states, but will then be subject to a new coordinated review.) Type of filing (please check or “X” one): _____ Small Company Offering Registration (SCOR Form U-7) _____ Question/Answer Form Model A under Regulation A _____ Offering Circular Model B under Regulation A Form 1-A (Traditional Disclosure) -Go to Next Page- American LegalNet, Inc. www.FormsWorkflow.com Midwest Regional Review Application Page 2 4. Undertakings of Applicant: The applicant agrees that it will file simultaneously in each state checked above. The applicant waives automatic effectiveness in each state checked above. The applicant agrees to resolve outstanding comments through the lead state and agrees to provide the lead state with a copy of the amended offering document marked to show changes. (Note: State-specific comments must be resolved with the state to which the comment applies.) The applicant understands that the securities to be registered must be sold by an agent that is either registered or exempt from registration in the subject state. The applicant agrees not to allow sales by agents that have not been registered or are not exempt in the state in which they are selling. Applicant Representative: ________________________________________________ Signature & Date ________________________________________________ Print Name ________________________________________________ Print Title American LegalNet, Inc. www.FormsWorkflow.com