APPLICATION FOR REGISTRATION OF SECURITIES BY QUALIFICATION REQUIREMENTS OF §75-71-304 OF THE MISSISSIPPI SECURITIES ACT OF 2010. Application is hereby made for the registration of securities by qualification described herein. 1. Name and address of issuer and address of principal office in this state, if any. PURSUANT TO THE 2. Name and address of applicant if different from the issuer. 3. Name, address, email address, and telephone number of person to whom notices and communications regarding this application may be sent. 4. Name, official capacity and residential address of officers, directors, trustees, partners, controlling persons and/or other officials of the issuer as of date of application. 5. State separately with respect to each kind, title, class or series of securities proposed to be offered in this state: Kind, Title, Class or Series Number of Shares or Units Maximum Price Per Share or Unit Aggregate Maximum Offering Price Form Registration by Qualification ­ Rev. 7/2013 Page 1 of 7 American LegalNet, Inc. www.FormsWorkFlow.com 6. If exact or variable offering price per share or unit is determined by a method or formula, include a statement of such method or formula for each separate kind, title, class or series as applicable, or refer to the proper location in the prospectus or other marketing material, including page numbers. 7. State the following about the issuer: a. State or foreign jurisdiction of organization; b. Date of organization; and c. Form of Organization. 8. Filing fees for registration of securities by qualification are based on the maximum aggregate offering price at which the registered securities are to be offered in this state, as follows: 1/10 of 1% of dollar amount to be registered ($300.00 minimum, $1,000.00 maximum) a. Amount of fee submitted with this application 9. Eligibility for sale in other states as of the date of this application: a. Other states, if any, in which application has been or is proposed to be made to render the securities eligible for sale; b. States, if any, in which the securities have been rendered so eligible as the result of such action; c. States, if any, which have refused by order or otherwise, to render the securities so eligible or have revoked or suspended the right to sell the securities, or in which an application for qualification has been withdrawn; and d. Have the securities been rendered eligible to be sold in the state of incorporation of the issuer and/or in the state where the principal place of business is located? (If the answer is no, state the reason or reasons) 10. If an application for registration of this offering has been filed with the Securities and Exchange Commission, state the date of such filing and the contemplated effective or commencement date of the offering. Form Registration by Qualification ­ Rev. 7/2013 Page 2 of 7 American LegalNet, Inc. www.FormsWorkFlow.com 11. A description and total number of any stock options or other security options, warrants or similar rights outstanding, or to be created in connection with the offering, and the amount of those options held or to be held by: a. b. Directors and officers of the issuer; Persons owning of record or owning beneficially, if known, ten percent (10%) or more of the outstanding shares of any kind, title, class or series of equity security of the issuer; Promoters of the issuer, if the issuer was organized within the previous three (3) years; Persons on whose behalf any part of the offering is to be made in a non-issuer distribution; Any person that holds or will hold ten percent (10%) or more in the aggregate of those options; and Underwriters. c. d. e. f. For the items listed above, please refer to the proper location in the prospectus or other offering material, including page numbers 12. Briefly describe the kind and amount of securities to be offered, and if applicable, the name and address of each underwriter and each recipient of a finder's fee or a description of the plan of distribution of securities that are to be offered otherwise than through an underwriter. Please refer to the proper location in the prospectus or other offering material, including page numbers. 13. State the total commissions or other remunerations to be paid in connection with the sale of the securities, including all incidental expenses, and give the percentage as to the total aggregate offering price of all the securities. Please refer to the proper location in the prospectus or other offering material, including page numbers. (The Secretary of State must approve such commissions before the securities shall be qualified and registered for sale in this state) 14. Submitted with this application and a part thereof are the following: a. b. A copy of the prospectus or offering circular. A copy of the issuer's articles of incorporation and by-laws or their substantial equivalents as currently in effect. A copy of any indenture, or other instrument under which the securities are to be issued or have been issued. A specimen copy of the securities or a copy of the form of instrument to evidence the securities. An opinion of counsel as to the validity of the securities. A copy of all escrow agreements, underwriting agreements and sales agreements pertaining to the securities. A copy of proposed advertisements and literature to be used in the sale of the securities, if any. c. d. e. f. g. Form Registration by Qualification ­ Rev. 7/2013 Page 3 of 7 American LegalNet, Inc. www.FormsWorkFlow.com h. A photocopy of any appraisals regarding real property, plants and equipment, if any, relating to the sale of the securities. A consent to service of process executed by the issuer or controlling person. Such document must be accompanied by a corporate resolution, if by a corporation, authorizing the persons executing the consent to service of process to do so. A balance sheet of the issuer as of a date within four (4) months prior to the filing of the application; a profit and loss statement and analysis of surplus for each of the three (3) fiscal years preceding the date of the balance sheet and for any period between the close of the last fiscal year and the date of the balance sheet or for the period of the issuer's and any predecessor' existence, if less than three (3) years. A copy of the subscription agreement to be used in the sale of securities. The written consent of any accountant, engineer, appraiser or other person whose profession gives authority t