30-10-105(8)(b), MCA Monica J. Lindeen Commissioner of Securities & Insurance Montana State Auditor 840 Helena Ave Helena, MT 59601 Phone: 406.444.2040 800.332.6148 Fax: 406.444.5558 www.csi.mt.gov APPLICATION FOR EXEMPTION FROM REGISTRATION 1. Name, address, and telephone number of issuer. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 2. Name, address, and telephone number of contact person. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 3. Description of Securities. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Type _______ _______ _______ _______ Units _______ _______ _______ _______ Amount _______ _______ _______ _______ Units in MT ____________ ____________ ____________ ____________ Amt. in MT ______________ ______________ ______________ ______________ 4(a). List the states in which it is proposed to offer the securities for sale. _______________________________________________________________________ _______________________________________________________________________ 4(b). List the states in which the securities are eligible for sale. _______________________________________________________________________ _______________________________________________________________________ 4(c). List the states which have refused, by order or otherwise, to authorize the sale of the securities, or have revoked or suspended the right to sell the securities, or in which an application has been withdrawn. _______________________________________________________________________ _______________________________________________________________________ 5. State the federal statute or rule under which the offering will be made. _______________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 6(a). Furnish the indicated information about each officer, director and promoter, and every individual who directly or indirectly owns or controls 10% or more of any class of security in the issuer. Name ______________ ______________ ______________ ______________ ______________ ______________ ______________ Position ______________ ______________ ______________ ______________ ______________ ______________ ______________ % OWNERSHIP BEFORE OFFERING __________________ __________________ __________________ __________________ __________________ __________________ __________________ % OWNERSHIP AFTER OFFERING ________________ ________________ ________________ ________________ ________________ ________________ ________________ 6(b). Provide the name of each listed person who, during the previous ten years, has been charged with or convicted of a felony, or entered a plea of guilty or nolo contendre to a felony charge involving fraud (including violation of any laws), embezzlement, fraudulent conversion, misappropriation of property or restraint of trade. Include the identity and location of the court and the penalty imposed or sought. ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 6(c). Provide the name of each listed person who, during the preceding ten years, has filed in bankruptcy or been adjudged bankrupt, or been recognized as insolvent. Provide the names of listed persons who have been a principal, director, executive officer, or general partner of a natural or artificial person who has filed in bankruptcy, been adjudged bankrupt, or been reorganized due to insolvency. Include the nature and date of the action. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 7. Offering: (a) Provide the names and addresses of the sales persons. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ (b) Describe all commissions and other expenses of the sale. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ (c) State whether investors are required to buy a minimum amount of the issue. If yes, describe: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com (d) If the offering is limited to a special group, describe the limitations. Examples are employees of the issuer, a certain number of individuals (as required to qualify under subchapter S of the Internal Revenue Code), persons of certain suitability characteristics, or any other limitations. ___________________________________________________________________ ___________________________________________________________________ (e) State whether a disclosure document is used in connection with sales or offers of the security. __________________ 8. Describe the restrictions on subsequent transfer of any interest in the securities. State whether the certificates bear a legend notifying holders of restrictions. ___________________________________________________________________ ___________________________________________________________________ 9. Summarize the business of the issuer. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ _____________________________________