(PROFIT) ANNUAL LIST OF OFFICERS, DIRECTORS AND REGISTERED AGENT AND STATE BUSINESS LICENSE APPLICATION OF: NAME OF CORPORATION FOR THE FILING PERIOD OF FILE NUMBER *110101* TO **YOU MAY FILE THIS FORM ONLINE AT www.nvsos.gov** *110101* The entity's duly appointed registered agent in the State of Nevada upon whom process can be served is: A FORM TO CHANGE REGISTERED AGENT INFORMATION IS FOUND AT: www.nvsos.gov USE BLACK INK ONLY - DO NOT HIGHLIGHT ABOVE SPACE IS FOR OFFICE USE ONLY Return one file stamped copy. (If filing not accompanied by order instructions, file stamped copy will be sent to registered agent.) IMPORTANT: Read instructions before completing and returning this form. 1. Print or type names and addresses, either residence or business, for all officers and directors. A President, Secretary, Treasurer, or equivalent of and all Directors must be named. There must be at least one director. An Officer must sign the form. FORM WILL BE RETURNED IF UNSIGNED. 2. If there are additional officers, attach a list of them to this form. 3. Return the complete form with the filing fee. Annual list fee is based upon the current total authorized stock as explained in the Annual List Fee Schedule For Profit Corporations. A $75.00 penalty must be added for failure to file this form by the deadline. An annual list received more than 90 days before its due date shall be deemed an amended list for the previous year. 4. State business license fee is $200.00. Effective 2/1/2010, $100.00 must be added for failure to file form by deadline. 5. Make your check payable to the Secretary of State. 6. Ordering Copies: If requested above, one file stamped copy will be returned at no additional charge. To receive a certified copy, enclose an additional $30.00 per certification. A copy fee of $2.00 per page is required for each additional copy generated when ordering 2 or more file stamped or certified copies. Appropriate instructions must accompany your order. 7. Return the completed form to: Secretary of State, 202 North Carson Street, Carson City, Nevada 89701-4201, (775) 684-5708. 8. Form must be in the possession of the Secretary of State on or before the last day of the month in which it is due. (Postmark date is not accepted as receipt date.) Forms received after due date will be returned for additional fees and penalties. Failure to include annual list and business license fees will result in rejection of filing. CHECK ONLY IF APPLICABLE Pursuant to NRS, this entity is exempt from the business license fee. Exemption code: Month and year your State Business License expires: 20 This corporation is a publicly traded corporation. The Central Index Key number is: Section 7(2) Exemption Codes 001 - Governmental Entity 002 - 501(c) Nonprofit Entity 003 - Home-based Business 005 - Motion Picture Company This publicly traded corporation is not required to have a Central Index Key number. NAME TITLE(S) PRESIDENT (OR EQUIVALENT OF) ADDRESS CITY STATE NAME ZIP CODE TITLE(S) SECRETARY (OR EQUIVALENT OF) ADDRESS CITY STATE NAME ZIP CODE TITLE(S) TREASURER (OR EQUIVALENT OF) ADDRESS CITY STATE NAME ZIP CODE TITLE(S) STATE ZIP CODE DIRECTOR ADDRESS CITY I declare, to the best of my knowledge under penalty of perjury, that the above mentioned entity has complied with the provisions of sections 6 to 18 of AB 146 of the 2009 session of the Nevada Legislature and acknowledge that pursuant to NRS 239.330, it is a category C felony to knowingly offer any false or forged instrument for filing in the Office of the Secretary of State. X Signature of Officer Title Date Nevada Secretary of State Annual List Profit Revised: 8-27-09 American LegalNet, Inc. www.FormsWorkFlow.com