Page 1 of 3 (Rev. 11/16/1998) STATE OF UTAH DEPARTMENT OF COMMERCE DIVISION OF SECURITIES FORM 10-2-1 Application for Registration by Qualification 1. Name of Issuer Phone (Street Address) (City & State) (Zip Code) 2. Name of Applicant Phone (Street Address) (City & State) (Zip Code) 3. Name of Correspondent Phone (Street Address) (City & State) (Zip Code) 4. Agent or Underwriter Phone (Street Address) (City & State) (Zip Code) 5. Transfer Agent Phone (Street Address) (City & State) (Zip Code) 6. Description of Securities to be offered in Utah a. Number of Shares or Units to be offered b. Class c. Proposed Offering Price per Share or Unit d. Amount in Dollars 7. a. List the states, other than Utah, in which the issuer or applicant proposes to offer the securities for sale to the public. b. List the states in which the securities are eligible for sale to the pub lic. 8. Maximum Commission to be paid American LegalNet, Inc. www.USCourtForms.com>>>> 2Form 10-2-1 (Rev. 11/16/98)Page 2 of 3 9. List the name and residential address of all directors or officers or partne rs of the issuer or individuals who own of record or beneficially 10% or more of the outstanding shares of any class of equity securities of the issuer. Name Address 10. a. Fund Impound Agent (Name and Address of Financial Institution) b. Term of Fund Impound (Expressed in months) 11. The issuers fiscal year ends 12. Are there (or have there been) any criminal or civil complaints, or inves tigations by the SEC, NASD, or other State Securities Department, covering the company or any of it s officers or directors? Yes ____ No ____. If answer is yes, explain. 13. The applicant hereby applies for registration of securities under Section 6 1-1-10 of the Utah Uniform Securities Act and in consideration thereof agrees: a. Within ten working days after the expiration of effectiveness of the registrat ion statement, sale of the entire amount of the securities registered in the offering, or termination of the offering, whichever occurs first, the issuer must file with the Division, a list of persons who have purchased or subscribed to the offering, inc luding the residential address of each purchaser, the date of and amount of securi ties purchased or subscribed to, and the consideration paid by each purchaser or subscriber; b. All amendments to the prospectus will be promptly filed with the Division, distributed to purchasers in the offering, and made a part of any prospectus used th ereafter; c. The Division, market makers and security holders will be promptly notified in writing of any change in the management, purpose, and control of the issuer, or an y material or adverse condition affecting the issuer, so long as the registration sta tement is effective; American LegalNet, Inc. www.USCourtForms.com>>>> 3Form 10-2-1 (Rev. 11/16/98) Page 3 of 3 d. Financial statements will be submitted to the Division in accordance with Section R164-10-2(H) of the Utah Administrative Code. 14. The applicant hereby affirms that no material contract, understanding or ag reement exists which is not reflected in the registration statement. State of ) ) ss. County of ) On , the undersigned, ,being first duly sworn, deposes and says that he or she has executed the fore going application for and on behalf of the applicant, that he or she is the of such applicant and is fully authorized to execute and file such appli cation; that he or she is familiar with such application, and that to the best of his or her knowledge, informa tion and belief, the statements made in such application are true and the documents submitted herewith are true copies of the original thereof. Signature Subscribed and sworn to before me this day of , . Notary Public The undersigned directors, officers, partner or partners of the issuer name d herein do hereby affirm that they have read this registration statement and all exhibits theret o, and that the contents thereof are true to the best of their knowledge and belief; and further that is hereby authorized to execute this registration statement on behalf of t he issuer, and continuing authority is hereby delegated to him or her to file any amendments, supplementary or periodic information thereto as may be applicable or required, pursuant to the Utah Uniform Securiti es Act, and rules promulgated thereunder. Signature Title American LegalNet, Inc. www.USCourtForms.com