S.A. 6 (1989) COMMONWEALTH OF VIRGINIA STATE CORPORATION COMMISSION DIVISION OF SECURITIES AND RETAIL FRANCHISING REGISTRATION BY NOTIFICATION Pursuant to 21 VAC 5-30-50 Non-Issuer Distribution Secondary Trading 1. Name and address of issuer: _______________________________________________________ ________________________________________________________________________ ______ 2. Name and address of registrant: ________________________________________ ____________ ________________________________________________________________________ ______ 3. Name, address and telephone number of correspondent to whom notice and c ommunications regarding this application may be sent:_________________________________ ______________ ______________________________________________________________________________ 4. Description of the securities to be registered: ________________________ __________________ ________________________________________________________________________ ______ 5. Offering price Number Amount ____________ X _________ = _______________ 6. Fee (1/20 of 1% of the Amount in 5 above; minimum fee $100; max imum fee $250): $_________________________ 7. Are the above described securities to be offered and sold directly or in directly for the benefit of the issuer? _______ YES _______ NO 8. Have securities of the same class as the security being registered previ ously been registered pursuant to the Virginia Securities Act, the Securities Act of 1933 or t he Securities Exchange Act of 1934? _______________________________________________________________ ________ If so, identify the Act and give the date of registration and the name o f the person by whom they were registered. _______________________________________________________ __________ ____________________________________________________________________________ __ 9. Were the securities being registered originally issued pursuant to a n exemption under 13.1- 514? _______ If so, state which exemption.______________________________ _____________ The registrant, after making reasonable inquiry, believes that the facts herein stated are true. Registrant : By : Title : Date: __________________________ American LegalNet, Inc. www.USCourtForms.com>>>> 2S.A. 6 (1989) INSTRUCTIONS 1. This statement must be accompanied by the fee shown on line 6, payable t o the Treasurer of Virginia. 2. Unless the registrant is notified to the contrary by the State Corporati on Commission, the registration becomes effective at 3 p.m. on the second full business day after the statement has been filed in the office of the Commission, if the statement is complete and states fact showing eligibility of the securities for registration by notification. If the statement is incomplete, the registration is not effective until after the last amendment thereto has been filed. 3. Securities issued before January 1, 1957, stand on the same footing as s ecurities issued after that date for the purpose of determining whether they were issued pursuant to an exemption in 13.1- 514. American LegalNet, Inc. www.USCourtForms.com