DEPARTMENT OF COMMERCE AND INSURANCE SECURITIES DIVISION STATE OF TENNESSEE SUITE 680, 500 JAMES ROBERTSON PARKWAY NASHVILLE, TENNESSEE 37243 615-741-2947 APPLICATION FOR REGISTRATION AS AN OIL AND GAS ISSUER DEALER USE TYPEWRITER. ANSWER EVERY QUESTION. 1. Name of Applicant 2. Principal Address (Physical and Post Office Box Address) 3. Person to contact concerning this application: Telephone No. ( Name ) 4. List names of each officer, director and persons with similar status or functions and each other person who directly or indirectly are owners of 20% or more of the applicant. Shareholders need not be reported if applicant is registered under the Securities and Exchange Act of 1934. Name % of ownership Name % of ownership Name % of ownership Name % of ownership Name % of ownership Name % of ownership (Please attach additional pages it needed.) 5. List names and home addresses of all persons that effect securities transactions for the applicant. (Physical and P.O. Box address) Name Address Name Address Name Address Name Address (Please attach additional pages if needed.) FORM NO.: IN-0911 American LegalNet, Inc. www.USCourtForms.com 6. Has any officer, director, agent (or any other person occupying a similar function) of the applicant ever: YES NO (a) filed an application for registration which included any untrue statement of a material fact required to be stated therein or necessary to make the statements therein, in light of the circumstances under which they were made, not misleading; (b) been convicted within the past ten (10) years of any misdemeanor involving any aspect of the securities business or an investment-related business, or any felony; (c) been or is permanently or temporarily enjoined by any court of competent jurisdiction from engaging in or continuing any conduct or practice involving any aspect of the securities business or any investment-related business; (d) been or is the subject of any order entered within the past ten (10) years by any agency of any jurisdiction having regulatory authority with respect to the securities business or any investment-related business, denying, revoking or suspending a registration as a broker-dealer, agent, investment adviser or the substantial equivalent of those terms as defined in this part, or ordering such person to cease and desist from continuing any conduct or practice involving any investment-related transaction based on fraud, deceit or misrepresentation, or provisions of applicable law similar to Section 48-16-121(a) and (b). (IF THE ANSWER TO ANY PARAGRAPH OF QUESTION #6 IS ''YES'' A FULL EXPLANATION MUST BE ATTACHED.) 7. Form U-2, Uniform Consent to Service of Process, is enclosed. (Appoint the Commissioner of the Department of Commerce and Insurance.) 8. Form U-2A, Uniform Form of Corporate Resolution, is enclosed. (If applicant is a corporation) 9. A filing fee of $ 100.00 is enclosed. (Make check payable to: TENNESSEE DEPARTMENT OF COMMERCE AND INSURANCE.) EXECUTION: The undersigned, being first duly sworn, deposes and says that he has executed this form on behalf of, and with the authority of, said applicant. The undersigned and applicant represent that the information and statements contained herein, including exhibits attached hereto and other information filed herewith, all of which are made a part hereof, are current, true, and complete. Dated the day of 19 (Name of Applicant) By: (Signature and Title) Subscribed and sworn to before me this day of 19 (Notary Public) My commission expires American LegalNet, Inc. www.USCourtForms.com