Securities Department 600 E Boulevard Ave - Dept 414 Bismarck, ND 58505 (701) 328-2910 www.ndsecurities.com APPLICATION FOR REGISTRATION OF SECURITIES BY ANNOUNCEMENT - SECONDARY SECURITIES DEPARTMENT SFN 54147 (8-2004) Under Section 10-04-07.1 of the Securities Act of 1951 as amended. Dealer Applicant Address City State Zip Code Principal Office Address City State Zip Code Title of Securities Being Registered Current Market Bid Ask Last Twelve Month Low Last Twelve Month Low Bid Last Twelve Month Low Ask 4 5 Average for Period Name of Issuer of Securities Being Registered Last Twelve Month High Last Twelve Month High Bid Last Twelve Month High Ask Earnings History per share for 5 years (except for newer companies) 1 2 3 Subject securities have been outstanding and in the hands of the public for not less than one year. No Yes Include a financial statement or Offering Circular containing a financial statement not more than 12 months old. If not available, indicate date when ready. Subject Securities Previously Registered In North Dakota Date of Latest Registration With Securities & Exchange Commission If the securities being registered are life insurance company stocks qualifying under the second paragraph of Section 10-0407.1 of the North Dakota Securities Act of 1951, as amended, please supply information as stated in Subsection 1 of Section 10-04-07.1. Securities entitled to registration by announcement may be registered only by a dealer registered in the office of the commissioner. The filling fee is twenty-five dollars ($25.00). The undersigned under oath says that he/she has executed the foregoing application for and on behalf of the applicant named above; that he/she is ___________________________ of such applicant and is fully authorized to execute and file such application; that he/she has read such application and knows the contents; and that to the best of his/her knowledge and belief the statement made in such application and the exhibits enclosed are true. Registered Dealer Corporate Seal By Date Signature and Official Capacity of Person Filing for Registered Dealer American LegalNet, Inc. www.USCourtForms.com