COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index D New Hampshire Form No. No. ____________________________ : Calendar No. STATE OF NEW HAMPSHIRE Rec'd __________________________ DEPARTMENT OF STATE App'd __________________________ : JUDICIAL SUBPOENA BUREAU OF SECURITIES REGULATIONPlaintiff(s) Fee ____________________________ Granted ________________________ -against: : Application for License for New Hampshire Issuer-Dealer : To the Secretary of State Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . . . . . for . . . . . . . . . . . . . . The undersigned . .hereby. .applies . . . . . . a. .license . authorizing it to sell its securities in this state under the New Hampshire Blue Sky Law and makes the following statement: 1. Name of applicant 2. Address of applicant THE PEOPLE OF 3. Telephone No. THE STATE OF NEW YORK 4. Date of incorporation or organization, and place: TO 5. (a) Type of Organization: Corporation Partnership/LLP Proprietorship Other LLC 6. Are you actually engaged in business in this state? 7. Give the names, residences, business addresses, capacity and title of all persons GREETINGS: interested in the business as principals, officers, directors, managers or managing agents. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Name Honorable Residence Business Address Capacity and Title , the at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to 8. Inthe partyother states this subpoena was issued for a maximum penalty of $50 and all damages sustained as a what on whose behalf have you ever applied for a securities license? result of your failure to comply. 9. In what other state are you licensed or registered? Witness, Honorable , one of the Justices of the 10.State briefly the general plan and character of the business of applicant, Court in County, day of 20 specifying the nature of property in which , it is proposed to deal,and the method of transacting business, whether by solicitation, advertisement, correspondence or otherwise. (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. 11.Type and amount of securities for which qualification is requested : : There are attached hereto and made a part hereof: Index No. Calendar No. : (a) Copy of charter, articles of incorporation, or limited liability company, or limited partnership JUDICIAL Plaintiff(s) agreement certified by proper state official. -against- SUBPOENA : (b) Copy of by-laws certified by Clerk of the Corporation : (c) Certified copies of Profit and Loss Statement and Balance Sheet as of last December 31, or close of fiscal year. : (d) Pro-forma Balance Sheet (if new entity with no operating history). Defendant(s) : ...................................................... (e) Copy of offering memorandum or prospectus. (f) Three references as to the business repute and character of applicant, from unaffiliated persons, including names, addresses, and telephone numbers. THE PEOPLE OF THE STATE OF NEW YORK (g) Form D-1, properly executed, by each of the persons signing below. TO (h) There is enclosed herewith the fee due on filing this application. (Corporate seal if incorporated) GREETINGS: THIS APPLICATION MUST BE SIGNED BY ALL THE OFFICERS, PRINCIPALS, DIRECTORS, MANAGERS, MANAGING AGENTS, OR PARTNERS OF THE CORPORATION OR OTHER LEGAL ENTITY. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , at the Court (Sign here) Honorable the 1.___________________________________ located at County of Date 5._________________________________________ Date 2._____________________________________ Date 6._________________________________________ Date in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the DOB SS# DOB SS# Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to DOBthe party on whose behalf this subpoena was issued for aDOB SS# maximum penalty of SS# and all damages sustained as a $50 result of your failure to comply. 3._____________________________________ Date Witness, Honorable DOBCourt in SS# County, 7_________________________________________ Date , one of the Justices of the day of 4._____________________________________ Date , 20 DOB SS# 8.________________________________________ Date (Attorney must sign above and type name below) DOB SS# DOB SS# Attorney(s) for STATE OF COUNTY OF Subscribed and sworn to before me this day of , Office and P.O. Address _________________________________________ Notary Public Telephone No.: My commission expires Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com