NEW JERSEY BUREAU OF SECURITIES 153 Halsey Street, 6th Floor Newark, New Jersey 07102 REQUEST FOR WAIVER OF EXEMPTION CONDITIONS Pursuant to N.J.S.A. 49:3-50(b)(9) Instructions: This form should be filed to request a waiver of one or more of the conditions under N.J.S.A. 49:3-50(b)(9). Please answer all questions and furnish all required exhibits. There is no fee for this application. ____________________________________________________________________________ Based on the following information, the undersigned requests a waiver of one or more of the conditions under N.J.S.A. 49:3-50(b)(9). 1. Offeror of securities: a. Name: ___________________________________________________________________ b. Address: _________________________________________________________________ c. Relationship to issuer: ______________________________________________________ d. Is offeror of securities a broker-dealer? Yes ____ No ____ e. If offeror of securities is a broker-dealer, is it registered with the Bureau? Yes ____ No ____ 2. Issuer of securities: a. Form of entity: Corp. ___ LLC ___ Business trust ___ Other (specify)_________________ b. Name: ___________________________________________________________________ c. Address: _________________________________________________________________ d. State of formation: ______________________________ Date: _____________________ 3. Securities to be sold: a. Title of securities offered: ___________________________________________________ b. Dollar amount to be sold in New Jersey: $_______________________________________ c. Number of units to be sold in New Jersey: ______________________________________ American LegalNet, Inc. www.USCourtForms.com Request for Waiver of Exemption Conditions Page 2 4. Compensation of offeror: a. Type of compensation of offeror: ______________________________________________ b. Dollar amount of compensation of offeror: $_____________________________________ 5. Compliance with Securities Act of 1933: a. Is offering registered under Act? Yes ____ No ____ b. Is offering exempt under Section 3(a)(11)? Yes ____ No ____ c. Is offering exempt under Section 4(2)? Yes ____ No ____ d. Is offering exempt under SEC Rule 504? Yes ____ No ____ e. Is offering exempt under SEC Rule 505? Yes ____ No ____ f. Is offering exempt under SEC Rule 506? Yes ____ No ____ 6. Investment restrictions: a. Does offering contain suitability requirements? Yes ____ No ____ b. Will securities be legended to restrict resale? Yes ____ No ____ c. Does offeror reasonably believe that all buyers are purchasing for investment? Yes ____ No ____ 7. If the following exist, they must be attached as exhibits: a. All offering materials Yes ____ No ____ b. Investment Yes ____ No____ Yes ____ No ____ Yes ____ No ____ American LegalNet, Inc. www.USCourtForms.com Request for Waiver of Exemption Conditions Page 3 8. Has offeror or its affiliates or agents made any offers of these securities in New Jersey within 12 months prior to this offering? Yes ____ No_____ If so, please provide the following information: Name and Address of Offeree _______________________________________ _______________________________________ _______________________________________ _______________________________________ Date ________________ ________________ ________________ ________________ Dollar Amount ____________ ____________ ____________ ____________ 9. Request for waiver: a. Applicant requests waiver of investment intent condition, N.J.S.A. 49:3-50(b)(9)(i). Yes ____ No ____ b. Applicant requests waiver of commission condition, N.J.S.A. 49:3-50(b)(9)(ii). Yes ____ No ____ c. Applicant requests increase in number of buyers from 10 to _____ (not more than 20 during a 12-month period). Yes ____ No ____ I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment. __________________________________ Name of offeror By: _______________________________ Title: ______________________________ Date: ______________________________ Phone: ____________________________ Fax: ______________________________ Form NJBOS-19 8/03 American LegalNet, Inc. www.USCourtForms.com